- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $25.70 / $51.29
| Professional | | $19.95 | $25.70 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $19.95 / $25.12
| Professional | 26 | $16.98 | $19.95 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $3.02 / $3.98 / $23.99
| Professional | TC | $3.02 | $3.98 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $19.95 / $25.12
| Professional | | $18.20 | $19.95 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $16.60 / $20.89
| Professional | 26 | $14.79 | $16.60 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $3.09 / $3.47 / $4.37
| Professional | TC | $3.09 | $3.47 | $4.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $28.84 / $72.44
| Professional | | $18.62 | $28.84 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $19.95 / $38.90
| Professional | 26 | $16.60 | $19.95 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $2.95 / $4.79 / $39.81
| Professional | TC | $2.95 | $4.79 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $100.00 / $100.00
| Facility | 26 | $47.86 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $47.86 / $316.23
| Professional | | $21.38 | $47.86 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $21.38 / $158.49
| Professional | 26 | $16.60 | $21.38 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $3.24 / $17.38 / $218.78
| Professional | TC | $3.24 | $17.38 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $32.36 / $58.88
| Professional | | $20.42 | $32.36 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $19.05 / $31.62
| Professional | 26 | $16.60 | $19.05 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $3.09 / $5.37 / $36.31
| Professional | TC | $3.09 | $5.37 | $36.31 |