- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $371.54 / $724.44
| Professional | | $134.90 | $371.54 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $134.90 / $269.15
| Professional | 26 | $72.44 | $134.90 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $295.12 / $537.03
| Professional | TC | $223.87 | $295.12 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | 26 | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $1,348.96
| Professional | | $489.78 | $489.78 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $269.15
| Professional | 26 | $85.11 | $85.11 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $467.74
| Professional | TC | $389.05 | $389.05 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $707.95 / $1,348.96
| Professional | | $416.87 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $93.33 / $204.17
| Professional | 26 | $83.18 | $93.33 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $549.54 / $1,071.52
| Professional | TC | $239.88 | $549.54 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Professional | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $302.00
| Professional | TC | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $954.99
| Professional | | $316.23 | $478.63 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $177.83
| Professional | 26 | $64.57 | $83.18 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $389.05 / $776.25
| Professional | TC | $275.42 | $389.05 | $776.25 |