- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Professional | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Professional | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | TC | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $223.87 / $346.74
| Professional | | $147.91 | $223.87 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $95.50
| Professional | 26 | $39.81 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $251.19
| Professional | TC | $104.71 | $162.18 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $204.17 / $501.19
| Professional | | $37.15 | $204.17 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $51.29 / $138.04
| Professional | 26 | $12.59 | $51.29 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $154.88 / $363.08
| Professional | TC | $24.55 | $154.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $77.62 / $245.47
| Professional | | $69.18 | $77.62 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $20.42 / $67.61
| Professional | 26 | $19.50 | $20.42 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $57.54 / $181.97
| Professional | TC | $50.12 | $57.54 | $181.97 |