- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $537.03 / $1,513.56
| Professional | | $309.03 | $537.03 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $141.25 / $275.42
| Professional | 26 | $85.11 | $141.25 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $288.40 / $588.84 / $812.83
| Professional | 52 | $288.40 | $588.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $354.81 / $588.84
| Professional | TC | $208.93 | $354.81 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $436.52
| Professional | | $131.83 | $131.83 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $162.18
| Facility | 26 | $131.83 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $537.03 / $891.25
| Professional | | $416.87 | $537.03 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $131.83 / $234.42
| Professional | 26 | $58.88 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $389.05 / $724.44
| Professional | TC | $204.17 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $512.86 / $912.01
| Professional | | $478.63 | $512.86 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $162.18
| Facility | 26 | $131.83 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $630.96 / $794.33
| Professional | | $416.87 | $630.96 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $131.83 / $190.55
| Professional | 26 | $87.10 | $131.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $323.59 / $512.86
| Professional | TC | $208.93 | $323.59 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $457.09 / $724.44
| Professional | | $269.15 | $457.09 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $194.98
| Professional | 26 | $77.62 | $77.62 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $338.84 / $588.84
| Professional | TC | $190.55 | $338.84 | $588.84 |