- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $38.02 / $77.62
| Professional | | $26.92 | $38.02 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $18.20 / $21.88
| Professional | 26 | $7.94 | $18.20 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $25.70 / $52.48
| Professional | TC | $18.20 | $25.70 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $446.68 / $588.84
| Facility | | $199.53 | $446.68 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $54.95 / $154.88
| Professional | | $46.77 | $54.95 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $13.80 / $36.31
| Professional | 26 | $13.80 | $13.80 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Professional | TC | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $407.38 / $407.38
| Facility | | $269.15 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $52.48 / $120.23
| Professional | | $44.67 | $52.48 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $16.98 / $36.31
| Professional | 26 | $12.59 | $16.98 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $33.88 / $83.18
| Professional | TC | $29.51 | $33.88 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Professional | | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Professional | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $25.70
| Professional | TC | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $47.86 / $100.00
| Professional | | $36.31 | $47.86 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $13.80 / $30.20
| Professional | 26 | $10.00 | $13.80 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $70.79
| Professional | TC | $25.70 | $34.67 | $70.79 |