- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $57.54 / $128.82
| Professional | | $43.65 | $57.54 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $26.30 / $38.90
| Professional | 26 | $15.14 | $26.30 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $30.90 / $89.13
| Professional | TC | $28.18 | $30.90 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $125.89
| Professional | | $38.90 | $38.90 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $125.89
| Professional | | $109.65 | $109.65 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $43.65
| Professional | 26 | $38.90 | $38.90 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $87.10
| Professional | TC | $66.07 | $66.07 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $134.90 / $154.88
| Professional | | $102.33 | $134.90 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $109.65 / $190.55
| Professional | | $67.61 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $38.90 / $57.54
| Professional | 26 | $23.99 | $38.90 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $66.07 / $134.90
| Professional | TC | $43.65 | $66.07 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $125.89
| Professional | | $43.65 | $43.65 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $43.65
| Professional | 26 | $16.22 | $16.22 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $27.54 / $77.62
| Professional | TC | $27.54 | $27.54 | $77.62 |