- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $112.20 / $575.44
| Professional | | $53.70 | $112.20 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $91.20 / $371.54
| Professional | 26 | $25.70 | $91.20 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $77.62 / $389.05
| Professional | TC | $29.51 | $77.62 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $54.95 / $120.23
| Professional | | $42.66 | $54.95 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Professional | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | TC | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $83.18 / $117.49
| Professional | | $27.54 | $83.18 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $44.67 / $162.18
| Professional | | $28.84 | $44.67 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $23.44 / $45.71
| Professional | 26 | $10.00 | $23.44 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $43.65 / $117.49
| Professional | TC | $18.62 | $43.65 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $123.03
| Facility | | $60.26 | $79.43 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $93.33 / $562.34
| Professional | | $42.66 | $93.33 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $32.36 / $173.78
| Professional | 26 | $17.38 | $32.36 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $64.57 / $389.05
| Professional | TC | $28.84 | $64.57 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $44.67 / $74.13
| Facility | | $29.51 | $44.67 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $104.71 / $489.78
| Professional | | $56.23 | $104.71 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $40.74 / $138.04
| Professional | 26 | $17.78 | $40.74 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $77.62 / $346.74
| Professional | TC | $38.90 | $77.62 | $346.74 |