- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $478.63 / $1,258.93
| Professional | | $213.80 | $478.63 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $120.23 / $331.13
| Professional | 26 | $66.07 | $120.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $331.13 / $676.08
| Professional | TC | $147.91 | $331.13 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $316.23
| Professional | | $107.15 | $107.15 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $131.83
| Facility | 26 | $107.15 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $676.08
| Professional | | $316.23 | $478.63 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $107.15 / $194.98
| Professional | 26 | $47.86 | $107.15 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $346.74 / $575.44
| Professional | TC | $138.04 | $346.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $363.08 / $707.95
| Professional | | $346.74 | $363.08 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $131.83
| Facility | 26 | $107.15 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $489.78 / $562.34
| Professional | | $316.23 | $489.78 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $107.15 / $158.49
| Professional | 26 | $70.79 | $107.15 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $251.19 / $426.58
| Professional | TC | $144.54 | $251.19 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $346.74 / $588.84
| Professional | | $194.98 | $346.74 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $158.49
| Professional | 26 | $63.10 | $74.13 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $245.47 / $478.63
| Professional | TC | $131.83 | $245.47 | $478.63 |