- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $123.03 / $158.49
| Professional | | $100.00 | $123.03 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $15.14 / $22.39
| Professional | 26 | $12.88 | $15.14 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $138.04
| Professional | TC | $87.10 | $107.15 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $138.04
| Professional | | $104.71 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $16.60 / $21.88
| Professional | 26 | $16.60 | $16.60 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $117.49
| Professional | TC | $89.13 | $89.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $125.89 / $181.97
| Professional | | $50.12 | $125.89 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $21.38 / $29.51
| Professional | 26 | $13.80 | $21.38 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $109.65 / $158.49
| Professional | TC | $75.86 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $102.33 / $186.21
| Professional | | $75.86 | $102.33 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $14.79 / $25.12
| Professional | 26 | $11.75 | $14.79 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $89.13 / $158.49
| Professional | TC | $66.07 | $89.13 | $158.49 |