- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $95.50 / $120.23
| Professional | | $77.62 | $95.50 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $46.77 / $61.66
| Professional | 26 | $38.90 | $46.77 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $47.86 / $57.54
| Professional | TC | $38.90 | $47.86 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $158.49
| Professional | | $128.82 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $77.62 / $77.62
| Professional | 26 | $63.10 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $79.43 / $79.43
| Professional | TC | $64.57 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $186.21
| Professional | | $114.82 | $147.91 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $74.13 / $100.00
| Professional | 26 | $60.26 | $74.13 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $91.20
| Professional | TC | $54.95 | $70.79 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $154.88 / $269.15
| Professional | | $81.28 | $154.88 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $81.28 / $147.91
| Professional | 26 | $51.29 | $81.28 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $67.61 / $107.15
| Professional | TC | $30.20 | $67.61 | $107.15 |