- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $107.15 / $257.04
| Professional | | $89.13 | $107.15 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $72.44 / $100.00
| Professional | 26 | $21.88 | $72.44 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $72.44 / $165.96
| Professional | TC | $63.10 | $72.44 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $234.42
| Professional | | $54.95 | $54.95 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $234.42
| Professional | | $177.83 | $177.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | 26 | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $181.97
| Professional | TC | $109.65 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $257.04 / $288.40
| Professional | | $194.98 | $257.04 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $331.13
| Professional | | $144.54 | $218.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $54.95 / $79.43
| Professional | 26 | $33.88 | $54.95 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $251.19
| Professional | TC | $109.65 | $169.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $77.62 / $218.78
| Professional | | $56.23 | $77.62 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $22.91 / $60.26
| Professional | 26 | $22.39 | $22.91 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $54.95 / $154.88
| Professional | TC | $33.11 | $54.95 | $154.88 |