- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $691.83 / $691.83
| Facility | | $20.89 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.02 / $3.39 / $3.39
| Facility | 26 | $3.02 | $3.39 | $3.39 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $25.12 / $48.98
| Professional | | $18.20 | $25.12 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.00 / $3.02 / $4.27
| Professional | 26 | $2.00 | $3.02 | $4.27 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $19.05 / $26.30
| Professional | TC | $15.85 | $19.05 | $26.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.72 / $22.91 / $33.88
| Facility | | $3.72 | $22.91 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.89 / $25.12 / $47.86
| Professional | | $3.89 | $25.12 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $35.48 / $35.48
| Facility | | $35.48 | $35.48 | $35.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.72 / $3.39 / $4.79
| Facility | 26 | $0.72 | $3.39 | $4.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $32.36 / $169.82
| Professional | | $19.95 | $32.36 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.69 / $5.13 / $51.29
| Professional | 26 | $2.69 | $5.13 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.49 / $28.18 / $95.50
| Professional | TC | $15.49 | $28.18 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $33.88 / $66.07
| Professional | | $17.78 | $33.88 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.88 / $7.94 / $16.22
| Professional | 26 | $2.88 | $7.94 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.79 / $26.92 / $51.29
| Professional | TC | $14.79 | $26.92 | $51.29 |