- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $478.63 / $1,230.27
| Professional | | $208.93 | $478.63 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $141.25 / $354.81
| Professional | 26 | $66.07 | $141.25 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $295.12 / $562.34
| Professional | TC | $131.83 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $309.03 / $309.03
| Professional | | $109.65 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $467.74 / $707.95
| Professional | | $288.40 | $467.74 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $109.65 / $194.98
| Professional | 26 | $48.98 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $302.00 / $501.19
| Professional | TC | $131.83 | $302.00 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $346.74 / $724.44
| Professional | | $331.13 | $346.74 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $446.68 / $549.54
| Professional | | $295.12 | $446.68 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $158.49
| Professional | 26 | $72.44 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $467.74
| Professional | TC | $134.90 | $208.93 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $346.74 / $616.60
| Professional | | $186.21 | $346.74 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $70.79 / $162.18
| Professional | 26 | $64.57 | $70.79 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $229.09 / $512.86
| Professional | TC | $123.03 | $229.09 | $512.86 |