- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $138.04 / $213.80
| Professional | | $69.18 | $138.04 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $30.20 / $54.95
| Professional | 26 | $19.95 | $30.20 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $123.03 / $218.78
| Professional | TC | $91.20 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $223.87 / $223.87
| Professional | | $181.97 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $40.74 / $40.74
| Professional | 26 | $33.88 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $181.97
| Professional | TC | $147.91 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $213.80 / $371.54
| Professional | | $131.83 | $213.80 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $37.15 / $50.12
| Professional | 26 | $19.05 | $37.15 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $234.42
| Professional | TC | $117.49 | $173.78 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $263.03 / $537.03
| Professional | | $131.83 | $263.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $43.65 / $69.18
| Professional | 26 | $19.05 | $43.65 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $213.80 / $489.78
| Professional | TC | $117.49 | $213.80 | $489.78 |