- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $436.52 / $1,479.11
| Facility | | $100.00 | $436.52 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $14.79 / $14.79
| Facility | 26 | $12.88 | $14.79 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $36.31 / $69.18
| Professional | | $28.84 | $36.31 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $19.95 / $48.98
| Professional | 26 | $12.02 | $19.95 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.78 / $22.39 / $38.90
| Professional | TC | $17.78 | $22.39 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $26.92 / $52.48
| Facility | | $14.45 | $26.92 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $30.90 / $58.88
| Professional | | $13.80 | $30.90 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Facility | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.31 / $15.49 / $21.88
| Facility | 26 | $3.31 | $15.49 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $50.12 / $177.83
| Professional | | $30.20 | $50.12 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $19.95 / $70.79
| Professional | 26 | $10.96 | $19.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.78 / $29.51 / $117.49
| Professional | TC | $17.78 | $29.51 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $295.12 / $1,174.90
| Facility | | $251.19 | $295.12 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $22.91 / $35.48
| Professional | 26 | $20.42 | $22.91 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $33.88 / $70.79
| Professional | | $25.12 | $33.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $14.79 / $30.20
| Professional | 26 | $11.22 | $14.79 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.45 / $19.50 / $38.02
| Professional | TC | $14.45 | $19.50 | $38.02 |