- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $338.84 / $630.96
| Professional | | $302.00 | $338.84 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $338.84
| Professional | 26 | $141.25 | $165.96 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $177.83 / $467.74
| Professional | TC | $158.49 | $177.83 | $467.74 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $575.44 / $870.96
| Professional | | $302.00 | $575.44 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $1,202.26
| Professional | 26 | $151.36 | $229.09 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $316.23 / $616.60
| Professional | TC | $158.49 | $316.23 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,513.56 / $2,290.87
| Professional | | $851.14 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $245.47 / $776.25 / $954.99
| Professional | 26 | $245.47 | $776.25 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $616.60 / $758.58 / $1,412.54
| Professional | TC | $616.60 | $758.58 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- 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
- $346.74 / $562.34 / $1,318.26
| Professional | | $346.74 | $562.34 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $186.21 / $269.15 / $776.25
| Professional | 26 | $186.21 | $269.15 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $302.00 / $537.03
| Professional | TC | $162.18 | $302.00 | $537.03 |