- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $263.03
| Professional | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Professional | 26 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | TC | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $331.13 / $524.81
| Professional | | $223.87 | $331.13 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $72.44 / $114.82
| Professional | 26 | $47.86 | $72.44 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $407.38
| Professional | TC | $169.82 | $257.04 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $275.42 / $741.31
| Professional | | $58.88 | $275.42 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $58.88 / $162.18
| Professional | 26 | $19.95 | $58.88 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $218.78 / $575.44
| Professional | TC | $38.90 | $218.78 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $354.81
| Professional | | $104.71 | $104.71 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $23.99 / $79.43
| Professional | 26 | $22.39 | $23.99 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $269.15
| Professional | TC | $81.28 | $81.28 | $269.15 |