- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Professional | 26 | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $33.11
| Professional | TC | $33.11 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $165.96
| Professional | | $69.18 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $67.61 / $107.15
| Professional | 26 | $43.65 | $67.61 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $37.15 / $58.88
| Professional | TC | $24.55 | $37.15 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $89.13 / $234.42
| Professional | | $28.18 | $89.13 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $53.70 / $151.36
| Professional | 26 | $18.62 | $53.70 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $9.77 / $34.67 / $83.18
| Professional | TC | $9.77 | $34.67 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $33.88 / $114.82
| Professional | | $33.11 | $33.88 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $22.39 / $75.86
| Professional | 26 | $20.42 | $22.39 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $11.75 / $12.88 / $41.69
| Professional | TC | $11.75 | $12.88 | $41.69 |