- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $371.54 / $1,148.15
| Professional | | $251.19 | $371.54 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $107.15 / $281.84
| Professional | 26 | $58.88 | $107.15 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $281.84 / $524.81
| Professional | TC | $186.21 | $281.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $380.19 / $380.19
| Professional | | $93.33 | $380.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $117.49
| Facility | 26 | $93.33 | $93.33 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $380.19 / $660.69
| Professional | | $245.47 | $380.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $93.33 / $169.82
| Professional | 26 | $41.69 | $93.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $269.15 / $489.78
| Professional | TC | $186.21 | $269.15 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $416.87 / $588.84
| Professional | | $380.19 | $416.87 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $117.49
| Facility | 26 | $93.33 | $93.33 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $537.03 / $660.69
| Professional | | $331.13 | $537.03 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $93.33 / $138.04
| Professional | 26 | $61.66 | $93.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $275.42 / $426.58
| Professional | TC | $194.98 | $275.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $281.84 / $489.78
| Professional | | $199.53 | $281.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $138.04
| Professional | 26 | $54.95 | $64.57 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $223.87 / $354.81
| Professional | TC | $144.54 | $223.87 | $354.81 |