- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $407.38
| Facility | | $177.83 | $239.88 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | TC | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.71 / $30.90 / $91.20
| Professional | | $8.71 | $30.90 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $12.02 / $44.67
| Professional | 26 | $7.08 | $12.02 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $38.02 / $77.62 / $251.19
| Professional | 50 | $38.02 | $77.62 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $21.88 / $87.10
| Professional | TC | $16.98 | $21.88 | $87.10 |
- 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
- $31.62 / $44.67 / $58.88
| Professional | | $31.62 | $44.67 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.59 / $10.72 / $14.13
| Professional | 26 | $7.59 | $10.72 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $32.36 / $44.67
| Professional | TC | $23.99 | $32.36 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $173.78 / $302.00
| Facility | | $128.82 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $51.29 / $83.18
| Professional | | $32.36 | $51.29 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.32 / $13.49 / $19.50
| Professional | 26 | $8.32 | $13.49 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $39.81 / $64.57
| Professional | TC | $25.12 | $39.81 | $64.57 |
- 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
- $29.51 / $40.74 / $53.70
| Professional | | $29.51 | $40.74 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.71 / $10.47 / $14.45
| Professional | 26 | $8.71 | $10.47 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $29.51 / $38.02
| Professional | TC | $20.42 | $29.51 | $38.02 |