- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $128.82 / $165.96
| Professional | | $120.23 | $128.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $15.14 / $18.20
| Professional | 26 | $12.88 | $15.14 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $147.91
| Professional | TC | $107.15 | $114.82 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $239.88 / $239.88
| Professional | | $194.98 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $25.70 / $25.70
| Professional | 26 | $20.89 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $213.80
| Professional | TC | $173.78 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $154.88
| Professional | | $77.62 | $102.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $15.14 / $22.39
| Professional | 26 | $11.75 | $15.14 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $83.18 / $131.83
| Professional | TC | $66.07 | $83.18 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $162.18 / $194.98
| Professional | | $93.33 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $22.39 / $30.20
| Professional | 26 | $16.22 | $22.39 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $169.82
| Professional | TC | $79.43 | $141.25 | $169.82 |