- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $208.93 / $389.05
| Facility | | $93.33 | $208.93 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $251.19 / $257.04
| Facility | TC | $134.90 | $251.19 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $44.67 / $107.15
| Professional | | $21.88 | $44.67 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $13.80 / $44.67
| Professional | 26 | $7.08 | $13.80 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $18.20 / $53.70
| Professional | TC | $14.13 | $18.20 | $53.70 |
- 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
- $26.30 / $37.15 / $54.95
| Professional | | $26.30 | $37.15 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.59 / $10.72 / $18.62
| Professional | 26 | $7.59 | $10.72 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $26.92 / $37.15
| Professional | TC | $18.62 | $26.92 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $43.65 / $69.18
| Professional | | $26.92 | $43.65 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $12.88 / $19.05
| Professional | 26 | $7.94 | $12.88 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $32.36 / $51.29
| Professional | TC | $19.95 | $32.36 | $51.29 |
- 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
- $24.55 / $34.67 / $45.71
| Professional | | $24.55 | $34.67 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.51 / $10.47 / $13.80
| Professional | 26 | $8.51 | $10.47 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $23.44 / $29.51
| Professional | TC | $16.22 | $23.44 | $29.51 |