- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $251.19
| Professional | | $97.72 | $114.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $64.57 / $151.36
| Professional | 26 | $57.54 | $64.57 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $50.12 / $95.50
| Professional | TC | $41.69 | $50.12 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $186.21 / $186.21
| Professional | | $151.36 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $107.15 / $107.15
| Professional | 26 | $85.11 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $81.28 / $81.28
| Professional | TC | $67.61 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $134.90 / $223.87
| Professional | | $100.00 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $89.13 / $128.82
| Professional | 26 | $69.18 | $89.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $40.74 / $81.28
| Professional | TC | $30.20 | $40.74 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $295.12
| Professional | | $128.82 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $107.15 / $208.93
| Professional | 26 | $89.13 | $107.15 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $54.95 / $102.33
| Professional | TC | $40.74 | $54.95 | $102.33 |