- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $199.53 / $446.68
| Professional | | $162.18 | $199.53 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $104.71 / $239.88
| Professional | 26 | $85.11 | $104.71 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $93.33 / $204.17
| Professional | TC | $75.86 | $93.33 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $213.80 / $288.40
| Professional | | $190.55 | $213.80 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $169.82
| Professional | 26 | $128.82 | $128.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $114.82
| Professional | TC | $87.10 | $87.10 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $251.19 / $436.52
| Professional | | $125.89 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $151.36 / $239.88
| Professional | 26 | $67.61 | $151.36 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $93.33 / $169.82
| Professional | TC | $56.23 | $93.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $213.80 / $309.03
| Professional | | $128.82 | $213.80 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $120.23 / $208.93
| Professional | 26 | $72.44 | $120.23 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $100.00 / $134.90
| Professional | TC | $54.95 | $100.00 | $134.90 |