- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $141.25
| Professional | | $95.50 | $112.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $81.28 / $117.49
| Professional | 26 | $70.79 | $81.28 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $30.90 / $39.81
| Professional | TC | $25.12 | $30.90 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $138.04
| Professional | | $104.71 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $107.15
| Professional | 26 | $81.28 | $81.28 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $30.90
| Professional | TC | $22.91 | $22.91 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $70.79 / $95.50
| Professional | | $24.55 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $181.97
| Professional | | $97.72 | $138.04 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $141.25
| Professional | 26 | $72.44 | $109.65 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $29.51 / $44.67
| Professional | TC | $19.50 | $29.51 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $181.97
| Professional | | $144.54 | $144.54 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $102.33 / $169.82
| Professional | | $81.28 | $102.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $131.83
| Professional | 26 | $58.88 | $77.62 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.38 / $25.12 / $44.67
| Professional | TC | $17.38 | $25.12 | $44.67 |