- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $67.61 / $275.42
| Professional | | $34.67 | $67.61 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $12.88 / $27.54
| Professional | 26 | $8.91 | $12.88 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $36.31 / $52.48
| Professional | TC | $25.70 | $36.31 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $70.79
| Professional | | $57.54 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $18.20 / $18.20
| Professional | 26 | $15.14 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $52.48 / $52.48
| Professional | TC | $41.69 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $79.43 / $186.21
| Professional | | $53.70 | $79.43 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $18.62 / $43.65
| Professional | 26 | $13.18 | $18.62 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $60.26 / $144.54
| Professional | TC | $40.74 | $60.26 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $97.72 / $173.78
| Professional | | $69.18 | $97.72 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $21.38 / $42.66
| Professional | 26 | $15.49 | $21.38 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $75.86 / $128.82
| Professional | TC | $51.29 | $75.86 | $128.82 |