- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $263.03
| Professional | | $54.95 | $70.79 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $25.12 / $64.57
| Professional | 26 | $14.45 | $25.12 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $54.95 / $91.20
| Professional | TC | $38.02 | $54.95 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $97.72
| Professional | | $23.44 | $23.44 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $29.51
| Facility | 26 | $23.44 | $23.44 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $79.43 / $147.91
| Professional | | $45.71 | $79.43 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $23.44 / $39.81
| Professional | 26 | $12.88 | $23.44 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $58.88 / $112.20
| Professional | TC | $32.36 | $58.88 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $162.18
| Professional | | $91.20 | $107.15 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $29.51
| Facility | 26 | $23.44 | $23.44 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $138.04 / $165.96
| Professional | | $77.62 | $138.04 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $23.44 / $34.67
| Professional | 26 | $15.49 | $23.44 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $67.61 / $107.15
| Professional | TC | $44.67 | $67.61 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $60.26 / $114.82
| Professional | | $57.54 | $60.26 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $17.38 / $85.11
| Professional | 26 | $16.22 | $17.38 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $43.65 / $87.10
| Professional | TC | $40.74 | $43.65 | $87.10 |