- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $77.62 / $165.96
| Professional | | $67.61 | $77.62 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $38.02 / $89.13
| Professional | 26 | $28.84 | $38.02 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $38.90 / $75.86
| Professional | TC | $33.11 | $38.90 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $128.82
| Professional | | $104.71 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $64.57
| Professional | 26 | $52.48 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $64.57
| Professional | TC | $52.48 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $151.36
| Professional | | $72.44 | $100.00 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $61.66 / $93.33
| Professional | 26 | $48.98 | $61.66 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $29.51 / $64.57
| Professional | TC | $21.88 | $29.51 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $208.93
| Professional | | $83.18 | $112.20 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $123.03
| Professional | 26 | $54.95 | $69.18 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $43.65 / $74.13
| Professional | TC | $29.51 | $43.65 | $74.13 |