- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $66.07 / $165.96
| Professional | | $54.95 | $66.07 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $48.98 / $229.09
| Professional | 26 | $39.81 | $48.98 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.38 / $19.95 / $48.98
| Professional | TC | $17.38 | $19.95 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $102.33
| Professional | | $72.44 | $72.44 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $89.13
| Facility | 26 | $72.44 | $72.44 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $83.18 / $194.98
| Professional | | $53.70 | $83.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $138.04
| Professional | 26 | $38.90 | $58.88 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $26.30 / $58.88
| Professional | TC | $15.85 | $26.30 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $112.20 / $295.12
| Professional | | $102.33 | $112.20 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $89.13
| Facility | 26 | $72.44 | $72.44 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $102.33 / $128.82
| Professional | | $61.66 | $102.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $64.57 / $89.13
| Professional | 26 | $43.65 | $64.57 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $26.92 / $38.02
| Professional | TC | $19.05 | $26.92 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $83.18 / $112.20
| Professional | | $77.62 | $83.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $58.88 / $79.43
| Professional | 26 | $54.95 | $58.88 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $23.99 / $32.36
| Professional | TC | $22.91 | $23.99 | $32.36 |