- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $169.82
| Professional | | $128.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $40.74
| Professional | 26 | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | TC | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $213.80 / $338.84
| Professional | | $141.25 | $213.80 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $79.43
| Professional | 26 | $51.29 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $257.04 / $257.04
| Professional | TC | $162.18 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $177.83 / $489.78
| Professional | | $48.98 | $177.83 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $40.74 / $112.20
| Professional | 26 | $14.13 | $40.74 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $138.04 / $371.54
| Professional | TC | $34.67 | $138.04 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $67.61 / $831.76
| Professional | | $64.57 | $67.61 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $16.60 / $208.93
| Professional | 26 | $15.49 | $16.60 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $52.48 / $630.96
| Professional | TC | $47.86 | $52.48 | $630.96 |