- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $263.03
| Professional | | $93.33 | $117.49 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $66.07 / $128.82
| Professional | 26 | $57.54 | $66.07 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $43.65 / $89.13
| Professional | TC | $28.18 | $43.65 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $389.05
| Professional | | $123.03 | $147.91 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $234.42
| Professional | | $114.82 | $169.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $125.89 / $144.54
| Professional | 26 | $81.28 | $125.89 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $53.70 / $100.00
| Professional | TC | $33.88 | $53.70 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $389.05
| Professional | | $125.89 | $138.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $218.78
| Professional | 26 | $79.43 | $89.13 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $60.26 / $77.62
| Professional | TC | $38.02 | $60.26 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $144.54 / $223.87
| Professional | | $95.50 | $144.54 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $100.00 / $144.54
| Professional | 26 | $57.54 | $100.00 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $47.86 / $100.00
| Professional | TC | $34.67 | $47.86 | $100.00 |