- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $199.53 / $363.08
| Professional | | $144.54 | $199.53 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $114.82 / $331.13
| Professional | 26 | $75.86 | $114.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $93.33 / $177.83
| Professional | TC | $70.79 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $416.87
| Professional | | $239.88 | $239.88 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $213.80
| Professional | 26 | $123.03 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $204.17
| Professional | TC | $120.23 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $141.25 / $398.11
| Professional | | $109.65 | $141.25 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $100.00 / $229.09
| Professional | 26 | $57.54 | $100.00 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $77.62 / $199.53
| Professional | TC | $48.98 | $77.62 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Professional | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | TC | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $234.42 / $389.05
| Professional | | $213.80 | $234.42 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $114.82 / $199.53
| Professional | 26 | $112.20 | $114.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $117.49 / $190.55
| Professional | TC | $104.71 | $117.49 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $331.13 / $537.03
| Professional | | $144.54 | $331.13 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $208.93 / $302.00
| Professional | 26 | $75.86 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $120.23 / $218.78
| Professional | TC | $64.57 | $120.23 | $218.78 |