- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $537.03 / $1,778.28
| Professional | | $295.12 | $537.03 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $154.88 / $457.09
| Professional | 26 | $85.11 | $154.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $371.54 / $645.65
| Professional | TC | $208.93 | $371.54 | $645.65 |
- 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
- $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 / $891.25
| Professional | | $478.63 | $512.86 | $891.25 |
- 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 / $630.96 / $794.33
| Professional | | $426.58 | $630.96 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $131.83 / $194.98
| Professional | 26 | $87.10 | $131.83 | $194.98 |
- 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 / $776.25
| Professional | | $269.15 | $457.09 | $776.25 |
- 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 / $346.74 / $588.84
| Professional | TC | $190.55 | $346.74 | $588.84 |