- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $389.05 / $1,230.27
| Facility | | $19.95 | $389.05 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.55 / $9.55 / $9.55
| Facility | 26 | $9.55 | $9.55 | $9.55 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $549.54 / $549.54
| Facility | TC | $302.00 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $48.98 / $208.93
| Professional | | $33.88 | $48.98 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $14.13 / $24.55
| Professional | 26 | $8.91 | $14.13 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $33.88 / $58.88
| Professional | TC | $21.88 | $33.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $131.83 / $131.83
| Professional | | $85.11 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $38.02 / $38.02
| Professional | 26 | $25.12 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $93.33 / $93.33
| Professional | TC | $60.26 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $54.95 / $93.33
| Professional | | $34.67 | $54.95 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $20.42 / $33.11
| Professional | 26 | $10.72 | $20.42 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $38.02 / $64.57
| Professional | TC | $23.99 | $38.02 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.08 / $11.75 / $131.83
| Facility | | $7.08 | $11.75 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $54.95 / $97.72
| Professional | | $34.67 | $54.95 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $17.38 / $33.88
| Professional | 26 | $10.96 | $17.38 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $37.15 / $64.57
| Professional | TC | $22.91 | $37.15 | $64.57 |