- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $436.52 / $1,023.29
| Professional | | $346.74 | $436.52 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $229.09
| Professional | 26 | $102.33 | $125.89 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $295.12 / $478.63
| Professional | TC | $229.09 | $295.12 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $512.86 / $794.33
| Professional | | $338.84 | $512.86 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $154.88 / $239.88
| Professional | 26 | $104.71 | $154.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $363.08 / $562.34
| Professional | TC | $234.42 | $363.08 | $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 / $151.36 / $229.09
| Professional | 26 | $131.83 | $151.36 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $371.54 / $549.54
| Professional | TC | $251.19 | $371.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $501.19 / $724.44
| Professional | | $389.05 | $501.19 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $154.88 / $213.80
| Professional | 26 | $128.82 | $154.88 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $346.74 / $501.19
| Professional | TC | $257.04 | $346.74 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $446.68 / $870.96
| Professional | | $338.84 | $446.68 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $234.42
| Professional | 26 | $104.71 | $134.90 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $645.65
| Professional | TC | $229.09 | $309.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $501.19 / $933.25
| Professional | | $380.19 | $501.19 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $229.09
| Professional | 26 | $128.82 | $158.49 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $338.84 / $575.44
| Professional | TC | $251.19 | $338.84 | $575.44 |