- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $190.55 / $389.05
| Facility | | $117.49 | $190.55 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Facility | 26 | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $131.83
| Facility | TC | $100.00 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $30.90 / $109.65
| Professional | | $10.72 | $30.90 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.76 / $16.98 / $40.74
| Professional | 26 | $6.76 | $16.98 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $33.88 / $107.15 / $199.53
| Professional | 50 | $33.88 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $19.95 / $67.61
| Professional | TC | $12.88 | $19.95 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $138.04 / $194.98
| Facility | | $93.33 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $36.31 / $60.26
| Professional | | $25.70 | $36.31 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.61 / $9.55 / $16.60
| Professional | 26 | $6.61 | $9.55 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $26.30 / $36.31
| Professional | TC | $19.05 | $26.30 | $36.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $302.00
| Facility | | $104.71 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $42.66 / $67.61
| Professional | | $26.30 | $42.66 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.41 / $11.48 / $17.78
| Professional | 26 | $7.41 | $11.48 | $17.78 |
- 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
- $23.99 / $33.11 / $42.66
| Professional | | $23.99 | $33.11 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.24 / $9.33 / $12.88
| Professional | 26 | $7.24 | $9.33 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $23.99 / $30.20
| Professional | TC | $16.98 | $23.99 | $30.20 |