- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $125.89 / $275.42
| Professional | | $89.13 | $125.89 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $39.81 / $165.96
| Professional | 26 | $22.91 | $39.81 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $91.20 / $204.17
| Professional | TC | $52.48 | $91.20 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $275.42
| Professional | | $158.49 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $61.66
| Professional | 26 | $36.31 | $36.31 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $213.80
| Professional | TC | $123.03 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $95.50 / $223.87
| Professional | | $43.65 | $95.50 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $29.51 / $77.62
| Professional | 26 | $16.98 | $29.51 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $56.23 / $154.88
| Professional | TC | $25.12 | $56.23 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $47.86
| Professional | 26 | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | TC | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $144.54 / $234.42
| Professional | | $128.82 | $144.54 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $33.88 / $58.88
| Professional | 26 | $32.36 | $33.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $109.65 / $177.83
| Professional | TC | $95.50 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $165.96 / $281.84
| Professional | | $58.88 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $58.88 / $91.20
| Professional | 26 | $22.39 | $58.88 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $102.33 / $199.53
| Professional | TC | $34.67 | $102.33 | $199.53 |