- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $407.38 / $954.99
| Professional | | $323.59 | $407.38 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $275.42
| Professional | 26 | $93.33 | $123.03 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $295.12 / $676.08
| Professional | TC | $229.09 | $295.12 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $363.08 / $407.38
| Professional | | $104.71 | $363.08 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $117.49 / $134.90
| Professional | 26 | $104.71 | $117.49 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $288.40 / $288.40
| Professional | TC | $257.04 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $446.68 / $1,023.29
| Professional | | $316.23 | $446.68 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $147.91 / $288.40
| Professional | 26 | $102.33 | $147.91 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $309.03 / $602.56
| Professional | TC | $208.93 | $309.03 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $407.38 / $676.08
| Professional | | $354.81 | $407.38 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $128.82 / $177.83
| Professional | 26 | $112.20 | $128.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $275.42 / $478.63
| Professional | TC | $239.88 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $398.11 / $707.95
| Professional | | $288.40 | $398.11 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $213.80
| Professional | 26 | $95.50 | $128.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $275.42 / $489.78
| Professional | TC | $194.98 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $457.09 / $549.54
| Professional | | $251.19 | $457.09 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $144.54 / $158.49
| Professional | 26 | $75.86 | $144.54 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $316.23 / $380.19
| Professional | TC | $173.78 | $316.23 | $380.19 |