- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $794.33
| Professional | | $125.89 | $173.78 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $112.20 / $251.19
| Professional | 26 | $67.61 | $112.20 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $70.79 / $154.88
| Professional | TC | $52.48 | $70.79 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $218.78
| Professional | | $100.00 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $77.62 / $125.89
| Professional | 26 | $53.70 | $77.62 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $54.95 / $93.33
| Professional | TC | $38.90 | $54.95 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $309.03
| Professional | | $144.54 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $112.20 / $169.82
| Professional | 26 | $81.28 | $112.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $79.43 / $134.90
| Professional | TC | $61.66 | $79.43 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $186.21 / $295.12
| Professional | | $147.91 | $186.21 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $151.36
| Professional | 26 | $83.18 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $81.28 / $120.23
| Professional | TC | $66.07 | $81.28 | $120.23 |