- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Professional | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | TC | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $234.42 / $371.54
| Professional | | $154.88 | $234.42 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $131.83 / $131.83
| Professional | 26 | $83.18 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $239.88 / $239.88
| Professional | TC | $151.36 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $190.55 / $512.86
| Professional | | $85.11 | $190.55 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $67.61 / $186.21
| Professional | 26 | $30.20 | $67.61 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $123.03 / $331.13
| Professional | TC | $54.95 | $123.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $77.62 / $257.04
| Professional | | $70.79 | $77.62 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $28.18 / $93.33
| Professional | 26 | $25.12 | $28.18 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $50.12 / $165.96
| Professional | TC | $46.77 | $50.12 | $165.96 |