- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | TC | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $338.84 / $467.74
| Professional | | $309.03 | $338.84 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $208.93
| Professional | 26 | $91.20 | $162.18 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $173.78 / $295.12
| Professional | TC | $147.91 | $173.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $676.08 / $707.95
| Professional | | $602.56 | $676.08 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $281.84 / $331.13 / $346.74
| Professional | 26 | $281.84 | $331.13 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $346.74 / $363.08
| Professional | TC | $309.03 | $346.74 | $363.08 |
- 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
- $323.59 / $512.86 / $724.44
| Facility | | $323.59 | $512.86 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | TC | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $602.56 / $660.69
| Professional | | $323.59 | $602.56 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $275.42 / $309.03
| Professional | 26 | $158.49 | $275.42 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $323.59 / $346.74
| Professional | TC | $173.78 | $323.59 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $588.84
| Professional | | $537.03 | $537.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $257.04 / $269.15
| Professional | 26 | $239.88 | $257.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $309.03
| Professional | TC | $288.40 | $288.40 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $338.84 / $660.69
| Professional | | $331.13 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $316.23
| Professional | 26 | $162.18 | $162.18 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $173.78 / $338.84
| Professional | TC | $165.96 | $173.78 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $346.74 / $489.78
| Professional | | $208.93 | $346.74 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $112.20 / $257.04
| Professional | 26 | $109.65 | $112.20 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $295.12
| Professional | TC | $97.72 | $162.18 | $295.12 |