- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Professional | 26 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | TC | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $275.42 / $436.52
| Professional | | $181.97 | $275.42 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $69.18 / $109.65
| Professional | 26 | $45.71 | $69.18 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $208.93 / $331.13
| Professional | TC | $138.04 | $208.93 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $239.88 / $660.69
| Professional | | $54.95 | $239.88 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $54.95 / $151.36
| Professional | 26 | $21.88 | $54.95 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $181.97 / $512.86
| Professional | TC | $33.11 | $181.97 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $89.13 / $309.03
| Professional | | $77.62 | $89.13 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $22.39 / $75.86
| Professional | 26 | $20.89 | $22.39 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $234.42
| Professional | TC | $54.95 | $69.18 | $234.42 |