- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $190.55 / $288.40
| Facility | | $131.83 | $190.55 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Facility | 26 | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $239.88 / $288.40
| Facility | TC | $104.71 | $239.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.49 / $32.36 / $114.82
| Professional | | $15.49 | $32.36 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $12.30 / $38.90
| Professional | 26 | $6.03 | $12.30 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $20.89 / $74.13
| Professional | TC | $15.85 | $20.89 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $138.04 / $194.98
| Facility | | $93.33 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $39.81 / $63.10
| Professional | | $28.18 | $39.81 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.61 / $9.55 / $17.38
| Professional | 26 | $6.61 | $9.55 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $29.51 / $40.74
| Professional | TC | $21.38 | $29.51 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $302.00
| Facility | | $117.49 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $46.77 / $74.13
| Professional | | $28.18 | $46.77 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $11.75 / $17.78
| Professional | 26 | $7.94 | $11.75 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $37.15 / $57.54
| Professional | TC | $22.39 | $37.15 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $36.31 / $46.77
| Professional | | $26.92 | $36.31 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $9.77 / $12.88
| Professional | 26 | $7.94 | $9.77 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $26.30 / $33.88
| Professional | TC | $19.50 | $26.30 | $33.88 |