- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $3,235.94 / $4,365.16
| Facility | | $257.04 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | TC | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $389.05 / $724.44
| Professional | | $323.59 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $177.83 / $602.56
| Professional | 26 | $144.54 | $177.83 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $223.87 / $478.63
| Professional | TC | $169.82 | $223.87 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $218.78
| Professional | 26 | $123.03 | $162.18 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $588.84 / $588.84
| Professional | | $288.40 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Professional | 26 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $501.19
| Professional | | $331.13 | $331.13 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $154.88 / $239.88
| Professional | 26 | $128.82 | $154.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $263.03
| Professional | TC | $173.78 | $173.78 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $3,235.94 / $4,365.16
| Facility | | $257.04 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | TC | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $549.54 / $1,023.29
| Professional | | $323.59 | $549.54 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $151.36 / $194.98 / $416.87
| Professional | 26 | $151.36 | $194.98 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $316.23 / $630.96
| Professional | TC | $169.82 | $316.23 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $389.05
| Professional | | $331.13 | $331.13 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $154.88
| Professional | 26 | $102.33 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $263.03
| Professional | TC | $173.78 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $467.74 / $812.83
| Professional | | $213.80 | $467.74 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $416.87
| Professional | 26 | $112.20 | $186.21 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $288.40 / $501.19
| Professional | TC | $102.33 | $288.40 | $501.19 |