- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $281.84
| Professional | | $114.82 | $181.97 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $23.99 / $52.48
| Professional | 26 | $19.95 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $147.91 / $245.47
| Professional | TC | $93.33 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $457.09
| Professional | | $169.82 | $169.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $28.84 / $85.11
| Professional | 26 | $28.84 | $28.84 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $204.17
| Professional | TC | $169.82 | $169.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $457.09
| Professional | | $138.04 | $204.17 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $28.18 / $85.11
| Professional | 26 | $20.42 | $28.18 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $158.49 / $295.12
| Professional | TC | $112.20 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $131.83 / $457.09
| Professional | | $128.82 | $131.83 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $26.30 / $85.11
| Professional | 26 | $23.44 | $26.30 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $169.82
| Professional | TC | $104.71 | $104.71 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $208.93 / $316.23
| Professional | | $117.49 | $208.93 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $29.51 / $56.23
| Professional | 26 | $22.39 | $29.51 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $245.47
| Professional | TC | $95.50 | $169.82 | $245.47 |