- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $524.81 / $1,778.28
| Professional | | $302.00 | $524.81 | $1,778.28 |
- 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
- TC
- Typical Low / Median / Typical High
- $213.80 / $338.84 / $660.69
| Professional | TC | $213.80 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $562.34
| Professional | | $131.83 | $131.83 | $562.34 |
- 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
- $426.58 / $537.03 / $891.25
| Professional | | $426.58 | $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
- $208.93 / $389.05 / $724.44
| Professional | TC | $208.93 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $524.81 / $933.25
| Professional | | $489.78 | $524.81 | $933.25 |
- 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
- $426.58 / $645.65 / $794.33
| Professional | | $426.58 | $645.65 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $131.83 / $194.98
| Professional | 26 | $89.13 | $131.83 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $331.13 / $512.86
| Professional | TC | $213.80 | $331.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $467.74 / $724.44
| Professional | | $275.42 | $467.74 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $83.18 / $194.98
| Professional | 26 | $77.62 | $83.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $346.74 / $588.84
| Professional | TC | $194.98 | $346.74 | $588.84 |