- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $114.82 / $323.59
| Professional | | $54.95 | $114.82 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $60.26 / $154.88
| Professional | 26 | $24.55 | $60.26 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.96 / $50.12 / $97.72
| Professional | TC | $10.96 | $50.12 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $85.11
| Professional | | $67.61 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $83.18
| Facility | 26 | $67.61 | $67.61 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $125.89 / $204.17
| Professional | | $77.62 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $52.48 / $77.62
| Professional | 26 | $32.36 | $52.48 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.38 / $83.18 / $131.83
| Professional | TC | $17.38 | $83.18 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $93.33 / $208.93
| Professional | | $91.20 | $93.33 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $83.18
| Facility | 26 | $67.61 | $67.61 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $114.82 / $177.83
| Professional | | $79.43 | $114.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $52.48 / $83.18
| Professional | 26 | $32.36 | $52.48 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.38 / $38.90 / $123.03
| Professional | TC | $17.38 | $38.90 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $114.82 / $194.98
| Professional | | $79.43 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $33.88 / $87.10
| Professional | 26 | $31.62 | $33.88 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $75.86 / $128.82
| Professional | TC | $46.77 | $75.86 | $128.82 |