- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $181.97 / $630.96
| Professional | | $100.00 | $181.97 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $144.54
| Professional | 26 | $37.15 | $56.23 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $125.89 / $213.80
| Professional | TC | $63.10 | $125.89 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $117.49 / $229.09
| Professional | | $89.13 | $117.49 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $43.65 / $70.79
| Professional | 26 | $30.20 | $43.65 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $74.13 / $131.83
| Professional | TC | $52.48 | $74.13 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $489.78
| Professional | | $131.83 | $199.53 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $63.10 / $95.50
| Professional | 26 | $45.71 | $63.10 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $128.82 / $407.38
| Professional | TC | $87.10 | $128.82 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $151.36 / $275.42
| Professional | | $117.49 | $151.36 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $58.88 / $85.11
| Professional | 26 | $46.77 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $102.33 / $169.82
| Professional | TC | $69.18 | $102.33 | $169.82 |