- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $537.03 / $1,737.80
| Professional | | $295.12 | $537.03 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $138.04 / $257.04
| Professional | 26 | $83.18 | $138.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $371.54 / $691.83
| Professional | TC | $208.93 | $371.54 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $436.52
| Professional | | $125.89 | $125.89 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $158.49
| Facility | 26 | $125.89 | $125.89 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $575.44 / $851.14
| Professional | | $281.84 | $575.44 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $125.89 / $229.09
| Professional | 26 | $57.54 | $125.89 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $436.52 / $707.95
| Professional | TC | $204.17 | $436.52 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $512.86 / $891.25
| Professional | | $467.74 | $512.86 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $158.49
| Facility | 26 | $125.89 | $125.89 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $630.96 / $758.58
| Professional | | $426.58 | $630.96 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $186.21
| Professional | 26 | $85.11 | $125.89 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $371.54 / $524.81
| Professional | TC | $213.80 | $371.54 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $457.09 / $758.58
| Professional | | $269.15 | $457.09 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $190.55
| Professional | 26 | $75.86 | $75.86 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $354.81 / $616.60
| Professional | TC | $190.55 | $354.81 | $616.60 |