- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Professional | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | 26 | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $45.71 / $45.71
| Professional | TC | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $346.74
| Professional | | $144.54 | $218.78 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $263.03 / $263.03
| Professional | 26 | $165.96 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $81.28 / $81.28
| Professional | TC | $52.48 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $181.97 / $489.78
| Professional | | $75.86 | $181.97 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $134.90 / $371.54
| Professional | 26 | $44.67 | $134.90 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $46.77 / $114.82
| Professional | TC | $31.62 | $46.77 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $70.79 / $234.42
| Professional | | $69.18 | $70.79 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $54.95 / $181.97
| Professional | 26 | $51.29 | $54.95 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $17.78 / $57.54
| Professional | TC | $15.85 | $17.78 | $57.54 |