- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $602.56 / $2,290.87
| Professional | | $371.54 | $602.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $186.21 / $549.54
| Professional | 26 | $97.72 | $186.21 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $446.68 / $1,621.81
| Professional | TC | $263.03 | $446.68 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $549.54 / $549.54
| Professional | | $162.18 | $549.54 | $549.54 |
- 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 / $1,096.48
| Professional | | $549.54 | $831.76 | $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
- $257.04 / $524.81 / $933.25
| Professional | TC | $257.04 | $524.81 | $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
- $269.15 / $467.74 / $870.96
| Professional | TC | $269.15 | $467.74 | $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 / $97.72 / $251.19
| Professional | 26 | $91.20 | $97.72 | $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 |