- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $123.03 / $223.87
| Professional | | $75.86 | $123.03 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $75.86 / $162.18
| Professional | 26 | $57.54 | $75.86 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $25.70 / $61.66
| Professional | TC | $18.20 | $25.70 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $112.20 / $151.36
| Professional | | $100.00 | $112.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $117.49
| Professional | 26 | $89.13 | $89.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $23.99 / $31.62
| Professional | TC | $23.99 | $23.99 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $128.82 / $204.17
| Professional | | $64.57 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $89.13 / $147.91
| Professional | 26 | $41.69 | $89.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $29.51 / $61.66
| Professional | TC | $19.50 | $29.51 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Professional | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $151.36
| Professional | | $64.57 | $104.71 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $74.13 / $102.33
| Professional | 26 | $48.98 | $74.13 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.79 / $29.51 / $50.12
| Professional | TC | $14.79 | $29.51 | $50.12 |