- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $69.18 / $89.13
| Professional | | $56.23 | $69.18 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $416.87 / $537.03
| Professional | 26 | $20.89 | $416.87 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $38.90 / $53.70
| Professional | TC | $34.67 | $38.90 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $489.78
| Professional | | $109.65 | $109.65 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $109.65 / $489.78
| Professional | | $83.18 | $109.65 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $38.90 / $120.23
| Professional | 26 | $27.54 | $38.90 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $120.23
| Professional | TC | $50.12 | $66.07 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $162.18
| Professional | | $72.44 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $28.18 / $40.74
| Professional | 26 | $27.54 | $28.18 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $81.28 / $120.23
| Professional | TC | $43.65 | $81.28 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $104.71 / $173.78
| Professional | | $56.23 | $104.71 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $34.67 / $43.65
| Professional | 26 | $18.20 | $34.67 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $64.57 / $131.83
| Professional | TC | $38.90 | $64.57 | $131.83 |