- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $169.82 / $295.12
| Professional | | $75.86 | $169.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $19.95 / $40.74
| Professional | 26 | $14.13 | $19.95 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $147.91 / $257.04
| Professional | TC | $58.88 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $131.83
| Professional | | $112.20 | $112.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $30.20
| Professional | 26 | $25.12 | $25.12 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $102.33
| Professional | TC | $87.10 | $87.10 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $87.10 / $346.74
| Professional | | $56.23 | $87.10 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $26.30 / $97.72
| Professional | 26 | $10.96 | $26.30 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $72.44 / $245.47
| Professional | TC | $43.65 | $72.44 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $158.49 / $213.80
| Professional | | $100.00 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $25.70 / $51.29
| Professional | 26 | $15.14 | $25.70 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $117.49 / $173.78
| Professional | TC | $83.18 | $117.49 | $173.78 |