- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $245.47 / $575.44
| Facility | | $114.82 | $245.47 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $295.12 / $575.44
| Facility | TC | $134.90 | $295.12 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $43.65 / $147.91
| Professional | | $10.96 | $43.65 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $15.14 / $47.86
| Professional | 26 | $8.91 | $15.14 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $39.81 / $117.49
| Professional | TC | $23.44 | $39.81 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $141.25 / $208.93
| Facility | | $112.20 | $141.25 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $60.26 / $77.62
| Professional | | $41.69 | $60.26 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $13.18 / $17.38
| Professional | 26 | $9.33 | $13.18 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $43.65 / $60.26
| Professional | TC | $32.36 | $43.65 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $302.00
| Facility | | $173.78 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $69.18 / $112.20
| Professional | | $43.65 | $69.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.77 / $15.85 / $23.44
| Professional | 26 | $9.77 | $15.85 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $54.95 / $89.13
| Professional | TC | $33.88 | $54.95 | $89.13 |
- 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
- $37.15 / $52.48 / $67.61
| Professional | | $37.15 | $52.48 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $12.88 / $16.98
| Professional | 26 | $10.47 | $12.88 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $50.12
| Professional | TC | $26.92 | $38.90 | $50.12 |