- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $93.33 / $134.90
| Professional | | $54.95 | $93.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $30.20 / $61.66
| Professional | 26 | $12.88 | $30.20 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $51.29 / $97.72
| Professional | TC | $28.84 | $51.29 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $93.33 / $263.03
| Professional | | $79.43 | $93.33 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $60.26
| Professional | 26 | $23.44 | $23.44 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $70.79
| Professional | TC | $60.26 | $60.26 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $89.13 / $199.53
| Professional | | $75.86 | $89.13 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $25.12 / $54.95
| Professional | 26 | $20.89 | $25.12 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $63.10 / $144.54
| Professional | TC | $52.48 | $63.10 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Professional | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $18.62 / $18.62
| Professional | 26 | $18.62 | $18.62 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $44.67
| Professional | TC | $44.67 | $44.67 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $81.28 / $158.49
| Professional | | $61.66 | $81.28 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $20.42 / $37.15
| Professional | 26 | $14.79 | $20.42 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $61.66 / $123.03
| Professional | TC | $45.71 | $61.66 | $123.03 |