- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $169.82 / $338.84
| Professional | | $100.00 | $169.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $48.98 / $181.97
| Professional | 26 | $38.90 | $48.98 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $89.13 / $234.42
| Professional | TC | $53.70 | $89.13 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $223.87
| Professional | | $109.65 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $41.69 / $91.20
| Professional | 26 | $28.84 | $41.69 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $93.33 / $158.49
| Professional | TC | $81.28 | $93.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $190.55 / $371.54
| Professional | | $95.50 | $190.55 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $53.70 / $91.20
| Professional | 26 | $33.88 | $53.70 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $123.03 / $275.42
| Professional | TC | $64.57 | $123.03 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $141.25 / $194.98
| Professional | | $100.00 | $141.25 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $50.12 / $69.18
| Professional | 26 | $40.74 | $50.12 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $87.10 / $144.54
| Professional | TC | $58.88 | $87.10 | $144.54 |