- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $50.12
| Facility | 26 | $2.00 | $2.00 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $30.20 / $77.62
| Professional | | $18.20 | $30.20 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.00 / $3.02 / $10.00
| Professional | 26 | $2.00 | $3.02 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $19.05 / $38.02
| Professional | TC | $15.14 | $19.05 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $21.38 / $40.74
| Professional | | $19.95 | $21.38 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.57 / $2.57 / $2.57
| Professional | 26 | $2.57 | $2.57 | $2.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $151.36 / $165.96
| Facility | | $64.57 | $151.36 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $33.11 / $61.66
| Professional | | $21.88 | $33.11 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.02 / $8.51 / $14.45
| Professional | 26 | $3.02 | $8.51 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $32.36 / $50.12 / $93.33
| Professional | 50 | $32.36 | $50.12 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $24.55 / $47.86
| Professional | TC | $18.20 | $24.55 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $20.89 / $29.51
| Facility | | $3.02 | $20.89 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $20.42 / $28.18
| Professional | | $3.02 | $20.42 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $64.57 / $165.96
| Facility | | $22.91 | $64.57 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $35.48 / $74.13
| Professional | | $20.42 | $35.48 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.82 / $5.50 / $16.60
| Professional | 26 | $2.82 | $5.50 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.38 / $29.51 / $52.48
| Professional | TC | $17.38 | $29.51 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.89 / $25.12 / $53.70
| Facility | | $3.89 | $25.12 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $25.70 / $53.70
| Professional | | $19.05 | $25.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.75 / $3.72 / $12.59
| Professional | 26 | $2.75 | $3.72 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $21.38 / $38.90
| Professional | TC | $16.22 | $21.38 | $38.90 |