- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $70.79 / $208.93
| Professional | | $42.66 | $70.79 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $20.42 / $43.65
| Professional | 26 | $12.02 | $20.42 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $46.77 / $91.20
| Professional | TC | $30.90 | $46.77 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $74.13 / $74.13
| Professional | | $19.50 | $74.13 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $23.99
| Facility | 26 | $19.50 | $19.50 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $67.61 / $112.20
| Professional | | $38.90 | $67.61 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $19.50 / $33.11
| Professional | 26 | $10.47 | $19.50 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $45.71 / $83.18
| Professional | TC | $28.84 | $45.71 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $81.28 / $123.03
| Professional | | $69.18 | $81.28 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $23.99
| Facility | 26 | $19.50 | $19.50 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $104.71 / $128.82
| Professional | | $58.88 | $104.71 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $19.50 / $28.18
| Professional | 26 | $12.30 | $19.50 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $48.98 / $79.43
| Professional | TC | $33.88 | $48.98 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $46.77 / $85.11
| Professional | | $41.69 | $46.77 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $13.80 / $85.11
| Professional | 26 | $12.88 | $13.80 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $33.11 / $63.10
| Professional | TC | $28.18 | $33.11 | $63.10 |