- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $295.12
| Professional | | $53.70 | $67.61 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $19.05 / $45.71
| Professional | 26 | $15.85 | $19.05 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $46.77 / $74.13
| Professional | TC | $37.15 | $46.77 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $109.65
| Professional | | $89.13 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $32.36 / $32.36
| Professional | 26 | $25.70 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $77.62 / $77.62
| Professional | TC | $64.57 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $138.04
| Professional | | $77.62 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $30.20 / $40.74
| Professional | 26 | $24.55 | $30.20 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $74.13 / $95.50
| Professional | TC | $52.48 | $74.13 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $204.17
| Professional | | $74.13 | $107.15 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $33.88 / $61.66
| Professional | 26 | $23.44 | $33.88 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $74.13 / $144.54
| Professional | TC | $51.29 | $74.13 | $144.54 |