- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $602.56 / $2,187.76
| Professional | | $371.54 | $602.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $194.98 / $588.84
| Professional | 26 | $104.71 | $194.98 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $446.68 / $1,230.27
| Professional | TC | $263.03 | $446.68 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $758.58
| Professional | | $162.18 | $162.18 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $199.53
| Facility | 26 | $162.18 | $162.18 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $812.83 / $1,096.48
| Professional | | $549.54 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $162.18 / $288.40
| Professional | 26 | $72.44 | $162.18 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $549.54 / $933.25
| Professional | TC | $251.19 | $549.54 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $645.65 / $1,122.02
| Professional | | $588.84 | $645.65 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $199.53
| Facility | 26 | $162.18 | $162.18 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $831.76 / $977.24
| Professional | | $549.54 | $831.76 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $162.18 / $239.88
| Professional | 26 | $107.15 | $162.18 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $457.09 / $870.96
| Professional | TC | $263.03 | $457.09 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $575.44 / $1,071.52
| Professional | | $338.84 | $575.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $251.19
| Professional | 26 | $91.20 | $100.00 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $446.68 / $891.25
| Professional | TC | $239.88 | $446.68 | $891.25 |