- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | TC | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,122.02 / $1,122.02
| Professional | | $446.68 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $575.44 / $575.44
| Professional | 26 | $223.87 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $562.34 / $562.34
| Professional | TC | $218.78 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | 26 | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | TC | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $218.78 / $724.44
| Professional | | $208.93 | $218.78 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $112.20 / $371.54
| Professional | 26 | $102.33 | $112.20 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $380.19
| Professional | TC | $97.72 | $114.82 | $380.19 |