- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $128.82 / $165.96
| Professional | | $112.20 | $128.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $15.14 / $19.50
| Professional | 26 | $12.88 | $15.14 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $114.82 / $147.91
| Professional | TC | $100.00 | $114.82 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $208.93
| Professional | | $22.91 | $22.91 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Facility | 26 | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $154.88 / $208.93
| Professional | | $85.11 | $154.88 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $20.89 / $23.44
| Professional | 26 | $12.02 | $20.89 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $134.90 / $186.21
| Professional | TC | $74.13 | $134.90 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $229.09 / $234.42
| Professional | | $169.82 | $229.09 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Facility | 26 | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $165.96 / $213.80
| Professional | | $85.11 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $20.89 / $23.99
| Professional | 26 | $12.02 | $20.89 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $141.25 / $186.21
| Professional | TC | $74.13 | $141.25 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $169.82 / $213.80
| Professional | | $131.83 | $169.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $24.55 / $27.54
| Professional | 26 | $17.78 | $24.55 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $186.21
| Professional | TC | $109.65 | $147.91 | $186.21 |