- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $691.83
| Facility | TC | $371.54 | $371.54 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $60.26 / $109.65
| Professional | | $27.54 | $60.26 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $33.88 / $81.28
| Professional | 26 | $19.95 | $33.88 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $77.62 / $234.42 / $338.84
| Professional | 50 | $77.62 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Professional | 52 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $51.29 / $67.61
| Professional | TC | $15.14 | $51.29 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $208.93 / $275.42
| Facility | | $100.00 | $208.93 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $36.31 / $95.50
| Professional | | $27.54 | $36.31 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $20.42 / $45.71
| Professional | 26 | $14.13 | $20.42 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $11.48 / $16.60 / $26.92
| Professional | TC | $11.48 | $16.60 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $75.86 / $138.04
| Professional | | $38.90 | $75.86 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $28.84 / $45.71
| Professional | 26 | $17.38 | $28.84 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.38 / $41.69 / $91.20
| Professional | TC | $17.38 | $41.69 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $63.10 / $104.71
| Professional | | $42.66 | $63.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $25.70 / $36.31
| Professional | 26 | $20.42 | $25.70 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $33.88 / $69.18
| Professional | TC | $19.95 | $33.88 | $69.18 |