- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $354.81 / $478.63
| Professional | | $288.40 | $354.81 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $151.36
| Professional | 26 | $83.18 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $323.59
| Professional | TC | $204.17 | $257.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $426.58 / $660.69
| Professional | | $269.15 | $426.58 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $194.98
| Professional | 26 | $85.11 | $125.89 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $295.12 / $457.09
| Professional | TC | $186.21 | $295.12 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $436.52 / $630.96
| Professional | | $346.74 | $436.52 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $123.03 / $186.21
| Professional | 26 | $107.15 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $331.13 / $446.68
| Professional | TC | $269.15 | $331.13 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $416.87 / $645.65
| Professional | | $338.84 | $416.87 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $125.89 / $169.82
| Professional | 26 | $104.71 | $125.89 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $380.19
| Professional | TC | $208.93 | $275.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $363.08 / $446.68
| Professional | | $309.03 | $363.08 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $100.00 / $123.03
| Professional | 26 | $87.10 | $100.00 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $263.03 / $323.59
| Professional | TC | $218.78 | $263.03 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $426.58 / $758.58
| Professional | | $338.84 | $426.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $125.89 / $186.21
| Professional | 26 | $104.71 | $125.89 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $288.40 / $478.63
| Professional | TC | $229.09 | $288.40 | $478.63 |