- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $54.95 / $95.50
| Professional | | $43.65 | $54.95 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $16.98 / $28.18
| Professional | 26 | $14.13 | $16.98 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $39.81 / $57.54
| Professional | TC | $28.84 | $39.81 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $26.30
| Facility | 26 | $21.88 | $21.88 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $69.18 / $114.82
| Professional | | $56.23 | $69.18 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $21.88 / $33.88
| Professional | 26 | $17.38 | $21.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $47.86 / $83.18
| Professional | TC | $38.02 | $47.86 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $77.62 / $107.15
| Professional | | $72.44 | $77.62 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $26.30
| Facility | 26 | $21.88 | $21.88 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $72.44 / $112.20
| Professional | | $48.98 | $72.44 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $20.89 / $27.54
| Professional | 26 | $14.13 | $20.89 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $47.86 / $63.10
| Professional | TC | $31.62 | $47.86 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $104.71
| Professional | | $66.07 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $25.12 / $30.90
| Professional | 26 | $18.62 | $25.12 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $60.26 / $70.79
| Professional | TC | $47.86 | $60.26 | $70.79 |