- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $446.68
| Facility | | $204.17 | $204.17 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.71 / $8.71 / $8.71
| Facility | 26 | $8.71 | $8.71 | $8.71 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $26.92
| Facility | TC | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $41.69 / $70.79
| Professional | | $37.15 | $41.69 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $10.96 / $21.88
| Professional | 26 | $7.94 | $10.96 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $33.11 / $52.48
| Professional | TC | $28.18 | $33.11 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $144.54 / $144.54
| Professional | | $91.20 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $33.88 / $33.88
| Professional | 26 | $21.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $109.65 / $109.65
| Professional | TC | $70.79 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $63.10 / $104.71
| Professional | | $37.15 | $63.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $19.50 / $36.31
| Professional | 26 | $11.48 | $19.50 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $44.67 / $70.79
| Professional | TC | $25.70 | $44.67 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.76 / $13.80 / $131.83
| Facility | | $7.76 | $13.80 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $61.66 / $107.15
| Professional | | $37.15 | $61.66 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $17.38 / $39.81
| Professional | 26 | $12.02 | $17.38 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $42.66 / $77.62
| Professional | TC | $25.12 | $42.66 | $77.62 |