- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $50.12
| Professional | 26 | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | TC | $117.49 | $117.49 | $117.49 |
- 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
- $41.69 / $64.57 / $100.00
| Professional | 26 | $41.69 | $64.57 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $245.47
| Professional | TC | $102.33 | $154.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $177.83 / $489.78
| Professional | | $53.70 | $177.83 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $51.29 / $141.25
| Professional | 26 | $17.78 | $51.29 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $125.89 / $346.74
| Professional | TC | $36.31 | $125.89 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $69.18 / $229.09
| Professional | | $67.61 | $69.18 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $21.38 / $70.79
| Professional | 26 | $19.05 | $21.38 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $162.18
| Professional | TC | $47.86 | $47.86 | $162.18 |