- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $134.90 / $229.09
| Professional | | $28.84 | $134.90 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $23.99 / $51.29
| Professional | 26 | $10.96 | $23.99 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $194.98
| Professional | TC | $91.20 | $107.15 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $263.03 / $263.03
| Professional | | $213.80 | $263.03 | $263.03 |
- 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
- $181.97 / $223.87 / $223.87
| Professional | TC | $181.97 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $645.65
| Professional | | $177.83 | $251.19 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $38.90 / $100.00
| Professional | 26 | $15.85 | $38.90 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $213.80 / $549.54
| Professional | TC | $151.36 | $213.80 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $275.42 / $501.19
| Professional | | $186.21 | $275.42 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $40.74 / $52.48
| Professional | 26 | $22.91 | $40.74 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $218.78 / $426.58
| Professional | TC | $154.88 | $218.78 | $426.58 |