- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Professional | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Professional | 26 | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | TC | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $407.38
| Professional | | $169.82 | $257.04 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $123.03
| Professional | 26 | $51.29 | $79.43 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $181.97 / $288.40
| Professional | TC | $120.23 | $181.97 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $234.42 / $588.84
| Professional | | $54.95 | $234.42 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $64.57 / $173.78
| Professional | 26 | $20.42 | $64.57 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $169.82 / $407.38
| Professional | TC | $33.88 | $169.82 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $288.40
| Professional | | $79.43 | $89.13 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $25.70 / $87.10
| Professional | 26 | $24.55 | $25.70 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $204.17
| Professional | TC | $54.95 | $64.57 | $204.17 |