- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $120.23 / $165.96
| Professional | | $91.20 | $120.23 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $14.13 / $18.20
| Professional | 26 | $11.48 | $14.13 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $141.25
| Professional | TC | $72.44 | $102.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $141.25
| Professional | | $114.82 | $114.82 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $18.20
| Professional | 26 | $16.22 | $16.22 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $131.83 / $177.83
| Professional | | $75.86 | $131.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $17.78 / $33.88
| Professional | 26 | $14.13 | $17.78 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $112.20 / $151.36
| Professional | TC | $61.66 | $112.20 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $34.67
| Facility | 26 | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $794.33
| Professional | | $91.20 | $117.49 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $17.78 / $134.90
| Professional | 26 | $12.30 | $17.78 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $100.00 / $707.95
| Professional | TC | $75.86 | $100.00 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $158.49
| Professional | | $85.11 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $16.98 / $21.88
| Professional | 26 | $12.30 | $16.98 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $95.50 / $141.25
| Professional | TC | $74.13 | $95.50 | $141.25 |