- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Professional | 26 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | TC | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $229.09 / $363.08
| Professional | | $138.04 | $229.09 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $54.95 / $87.10
| Professional | 26 | $36.31 | $54.95 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $275.42
| Professional | TC | $114.82 | $173.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $181.97 / $512.86
| Professional | | $36.31 | $181.97 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $44.67 / $123.03
| Professional | 26 | $14.45 | $44.67 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $138.04 / $389.05
| Professional | TC | $21.88 | $138.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $234.42
| Professional | | $56.23 | $67.61 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $18.20 / $60.26
| Professional | 26 | $16.60 | $18.20 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $51.29 / $177.83
| Professional | TC | $38.02 | $51.29 | $177.83 |