- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $426.58 / $691.83
| Professional | | $275.42 | $426.58 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $213.80
| Professional | 26 | $85.11 | $125.89 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $295.12 / $478.63
| Professional | TC | $190.55 | $295.12 | $478.63 |
- 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
- $389.05 / $389.05 / $1,202.26
| Professional | | $389.05 | $389.05 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $354.81
| Professional | 26 | $112.20 | $112.20 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $316.23
| Professional | TC | $275.42 | $275.42 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $794.33 / $1,318.26
| Professional | | $371.54 | $794.33 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $123.03 / $269.15
| Professional | 26 | $107.15 | $123.03 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $501.19 / $954.99
| Professional | TC | $190.55 | $501.19 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Professional | 26 | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $245.47
| Professional | TC | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $446.68 / $1,071.52
| Professional | | $302.00 | $446.68 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $223.87
| Professional | 26 | $87.10 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $812.83
| Professional | TC | $213.80 | $302.00 | $812.83 |