- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $426.58 / $891.25
| Professional | | $371.54 | $426.58 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $165.96 / $218.78
| Professional | 26 | $95.50 | $165.96 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $295.12 / $630.96
| Professional | TC | $257.04 | $295.12 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $524.81
| Facility | 26 | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $912.01
| Professional | | $831.76 | $831.76 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $131.83
| Professional | 26 | $112.20 | $112.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Professional | TC | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $1,096.48 / $2,238.72
| Professional | | $478.63 | $1,096.48 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $269.15
| Professional | 26 | $109.65 | $125.89 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $707.95 / $1,949.84
| Professional | TC | $363.08 | $707.95 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | 26 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $524.81
| Professional | TC | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $537.03 / $1,412.54
| Professional | | $380.19 | $537.03 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $223.87
| Professional | 26 | $87.10 | $112.20 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $426.58 / $1,258.93
| Professional | TC | $288.40 | $426.58 | $1,258.93 |