- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $398.11 / $724.44
| Professional | | $309.03 | $398.11 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $186.21 / $512.86
| Professional | 26 | $91.20 | $186.21 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $478.63
| Professional | TC | $158.49 | $218.78 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $363.08
| Professional | | $173.78 | $173.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $147.91
| Professional | 26 | $74.13 | $74.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $199.53
| Professional | TC | $100.00 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $354.81 / $407.38
| Professional | | $177.83 | $354.81 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $186.21 / $204.17 / $223.87
| Professional | 26 | $186.21 | $204.17 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $186.21 / $223.87
| Professional | TC | $173.78 | $186.21 | $223.87 |
- 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
- $354.81 / $446.68 / $501.19
| Professional | | $354.81 | $446.68 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $199.53 / $234.42
| Professional | 26 | $165.96 | $199.53 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $239.88 / $281.84
| Professional | TC | $186.21 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $537.03 / $1,318.26
| Facility | | $309.03 | $537.03 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $380.19 / $707.95
| Facility | | $190.55 | $380.19 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $588.84 / $812.83
| Professional | | $234.42 | $588.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $177.83 / $269.15 / $407.38
| Professional | 26 | $177.83 | $269.15 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $338.84 / $467.74
| Professional | TC | $239.88 | $338.84 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $478.63 / $1,023.29
| Professional | | $208.93 | $478.63 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $186.21 / $371.54
| Professional | 26 | $109.65 | $186.21 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $323.59 / $758.58
| Professional | TC | $97.72 | $323.59 | $758.58 |