- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $398.11
| Professional | | $87.10 | $112.20 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $39.81 / $131.83
| Professional | 26 | $30.90 | $39.81 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $72.44 / $269.15
| Professional | TC | $53.70 | $72.44 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $295.12 / $302.00
| Professional | | $263.03 | $295.12 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $107.15 / $107.15
| Professional | 26 | $95.50 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $190.55 / $190.55
| Professional | TC | $169.82 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $190.55
| Professional | | $154.88 | $154.88 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $67.61
| Professional | 26 | $54.95 | $54.95 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $123.03
| Professional | TC | $100.00 | $100.00 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $281.84 / $891.25
| Professional | | $269.15 | $281.84 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $102.33 / $338.84
| Professional | 26 | $97.72 | $102.33 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $549.54
| Professional | TC | $173.78 | $181.97 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $245.47 / $309.03
| Professional | | $131.83 | $245.47 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $87.10 / $109.65
| Professional | 26 | $47.86 | $87.10 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $154.88 / $199.53
| Professional | TC | $85.11 | $154.88 | $199.53 |