- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $489.78 / $870.96
| Professional | | $338.84 | $489.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $158.49 / $371.54
| Professional | 26 | $123.03 | $158.49 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $309.03 / $588.84
| Professional | TC | $223.87 | $309.03 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $69,183.10 / $95,499.26
| Facility | | $1,071.52 | $69,183.10 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $602.56
| Professional | | $194.98 | $194.98 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | 26 | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $562.34 / $602.56
| Professional | | $389.05 | $562.34 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $194.98 / $239.88
| Professional | 26 | $162.18 | $194.98 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $346.74 / $416.87
| Professional | TC | $223.87 | $346.74 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $660.69 / $741.31
| Facility | | $575.44 | $660.69 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $660.69 / $741.31
| Professional | | $575.44 | $660.69 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $537.03 / $676.08
| Facility | | $346.74 | $537.03 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | 26 | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $602.56 / $870.96
| Professional | | $389.05 | $602.56 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $275.42
| Professional | 26 | $128.82 | $194.98 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $389.05 / $562.34
| Professional | TC | $263.03 | $389.05 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $1,412.54
| Facility | | $446.68 | $446.68 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $602.56 / $1,071.52
| Professional | | $478.63 | $602.56 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $338.84
| Professional | 26 | $173.78 | $213.80 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $389.05 / $724.44
| Professional | TC | $302.00 | $389.05 | $724.44 |