- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $436.52 / $831.76
| Professional | | $354.81 | $436.52 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $128.82 / $204.17
| Professional | 26 | $107.15 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $288.40 / $467.74
| Professional | TC | $251.19 | $288.40 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $512.86 / $794.33
| Professional | | $331.13 | $512.86 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $245.47
| Professional | 26 | $104.71 | $158.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $354.81 / $562.34
| Professional | TC | $223.87 | $354.81 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $512.86 / $776.25
| Professional | | $380.19 | $512.86 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $154.88 / $234.42
| Professional | 26 | $131.83 | $154.88 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $371.54 / $537.03
| Professional | TC | $245.47 | $371.54 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $489.78 / $707.95
| Professional | | $380.19 | $489.78 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $158.49 / $213.80
| Professional | 26 | $131.83 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $331.13 / $489.78
| Professional | TC | $245.47 | $331.13 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $426.58 / $501.19
| Professional | | $354.81 | $426.58 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $128.82 / $151.36
| Professional | 26 | $109.65 | $128.82 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $288.40 / $371.54
| Professional | TC | $239.88 | $288.40 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $489.78 / $912.01
| Professional | | $380.19 | $489.78 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $158.49 / $234.42
| Professional | 26 | $131.83 | $158.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $331.13 / $562.34
| Professional | TC | $245.47 | $331.13 | $562.34 |