- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $602.56 / $2,187.76
| Professional | | $389.05 | $602.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $190.55 / $537.03
| Professional | 26 | $95.50 | $190.55 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $426.58 / $1,148.15
| Professional | TC | $269.15 | $426.58 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $549.54 / $549.54
| Professional | | $158.49 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $194.98
| Facility | 26 | $158.49 | $158.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $794.33 / $1,071.52
| Professional | | $549.54 | $794.33 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $158.49 / $281.84
| Professional | 26 | $70.79 | $158.49 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $512.86 / $933.25
| Professional | TC | $257.04 | $512.86 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $645.65 / $1,096.48
| Professional | | $588.84 | $645.65 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $194.98
| Facility | 26 | $158.49 | $158.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $831.76 / $977.24
| Professional | | $549.54 | $831.76 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $234.42
| Professional | 26 | $104.71 | $158.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $467.74 / $870.96
| Professional | TC | $269.15 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $562.34 / $1,047.13
| Professional | | $338.84 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $234.42
| Professional | 26 | $87.10 | $93.33 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $457.09 / $891.25
| Professional | TC | $245.47 | $457.09 | $891.25 |