- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $131.83 / $186.21
| Professional | | $107.15 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $46.77 / $61.66
| Professional | 26 | $39.81 | $46.77 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $83.18 / $134.90
| Professional | TC | $67.61 | $83.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $218.78
| Professional | | $177.83 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $77.62 / $77.62
| Professional | 26 | $64.57 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $141.25
| Professional | TC | $114.82 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $245.47 / $389.05
| Professional | | $181.97 | $245.47 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $74.13 / $100.00
| Professional | 26 | $60.26 | $74.13 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $295.12
| Professional | TC | $114.82 | $154.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $223.87 / $416.87
| Professional | | $134.90 | $223.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $83.18 / $151.36
| Professional | 26 | $52.48 | $83.18 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $144.54 / $269.15
| Professional | TC | $83.18 | $144.54 | $269.15 |