- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $199.53 / $363.08
| Professional | | $128.82 | $199.53 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $109.65 / $275.42
| Professional | 26 | $75.86 | $109.65 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $97.72 / $177.83
| Professional | TC | $52.48 | $97.72 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | 26 | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $251.19
| Professional | | $213.80 | $213.80 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $151.36
| Professional | 26 | $125.89 | $125.89 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $100.00
| Professional | TC | $85.11 | $85.11 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $125.89 / $478.63
| Professional | | $95.50 | $125.89 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $213.80
| Professional | 26 | $57.54 | $77.62 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $52.48 / $234.42
| Professional | TC | $37.15 | $52.48 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $213.80 / $331.13
| Professional | | $134.90 | $213.80 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $147.91
| Professional | 26 | $77.62 | $117.49 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $117.49
| Professional | TC | $56.23 | $85.11 | $117.49 |