- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $398.11 / $1,148.15
| Professional | | $275.42 | $398.11 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $186.21 / $389.05
| Professional | 26 | $91.20 | $186.21 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $524.81
| Professional | TC | $138.04 | $218.78 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $331.13 / $371.54
| Professional | | $173.78 | $331.13 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $173.78 / $194.98 / $223.87
| Professional | 26 | $173.78 | $194.98 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $204.17
| Professional | TC | $162.18 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | 26 | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | TC | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $457.09 / $588.84
| Professional | | $380.19 | $457.09 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $173.78 / $208.93 / $263.03
| Professional | 26 | $173.78 | $208.93 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $323.59
| Professional | TC | $204.17 | $245.47 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $371.54 / $676.08
| Professional | | $239.88 | $371.54 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $275.42
| Professional | 26 | $114.82 | $147.91 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $177.83 / $407.38
| Professional | TC | $114.82 | $177.83 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $537.03 / $588.84
| Professional | | $467.74 | $537.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $263.03
| Professional | 26 | $208.93 | $251.19 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $288.40 / $323.59
| Professional | TC | $257.04 | $288.40 | $323.59 |