- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $588.84 / $1,000.00
| Facility | | $446.68 | $588.84 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | TC | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $77.62
| Professional | | $25.70 | $34.67 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $20.42 / $24.55
| Professional | 26 | $8.91 | $20.42 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $25.12 / $47.86
| Professional | TC | $16.98 | $25.12 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $426.58 / $588.84
| Facility | | $186.21 | $426.58 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Facility | 26 | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | TC | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $51.29 / $141.25
| Professional | | $43.65 | $51.29 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $40.74
| Professional | 26 | $14.13 | $14.13 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $29.51 / $34.67
| Professional | TC | $29.51 | $29.51 | $34.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $478.63 / $478.63
| Facility | | $269.15 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $46.77 / $109.65
| Professional | | $41.69 | $46.77 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $15.49 / $33.88
| Professional | 26 | $13.18 | $15.49 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $32.36 / $72.44
| Professional | TC | $27.54 | $32.36 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $11.22 / $11.22
| Professional | 26 | $11.22 | $11.22 | $11.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Professional | TC | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $44.67 / $114.82
| Professional | | $32.36 | $44.67 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $14.45 / $28.84
| Professional | 26 | $10.47 | $14.45 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $29.51 / $63.10
| Professional | TC | $21.88 | $29.51 | $63.10 |