- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $33.11
| Facility | TC | $33.11 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $48.98 / $120.23
| Professional | | $36.31 | $48.98 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $16.98 / $54.95
| Professional | 26 | $12.02 | $16.98 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $33.11 / $79.43
| Professional | TC | $24.55 | $33.11 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $11.22 / $11.22
| Facility | 26 | $9.33 | $11.22 | $11.22 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $27.54 / $27.54
| Facility | TC | $22.91 | $27.54 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $112.20 / $162.18
| Professional | | $74.13 | $112.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $33.11 / $47.86
| Professional | 26 | $21.88 | $33.11 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $83.18 / $112.20
| Professional | TC | $52.48 | $83.18 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $47.86 / $117.49
| Facility | 26 | $20.42 | $47.86 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $117.49 / $288.40
| Facility | TC | $41.69 | $117.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $87.10 / $138.04
| Professional | | $54.95 | $87.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $25.12 / $40.74
| Professional | 26 | $17.78 | $25.12 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $35.48 / $61.66 / $97.72
| Professional | TC | $35.48 | $61.66 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $46.77 / $91.20
| Facility | 26 | $38.02 | $46.77 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $223.87
| Facility | TC | $91.20 | $114.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $112.20
| Professional | | $67.61 | $67.61 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $35.48
| Professional | 26 | $19.95 | $19.95 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $79.43
| Professional | TC | $47.86 | $47.86 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | TC | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $79.43 / $316.23
| Professional | | $44.67 | $79.43 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $26.92 / $107.15
| Professional | 26 | $14.79 | $26.92 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $51.29 / $295.12
| Professional | TC | $30.20 | $51.29 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $85.11 / $338.84
| Professional | | $50.12 | $85.11 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $85.11 / $112.20
| Professional | 26 | $17.78 | $85.11 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $48.98 / $97.72
| Professional | TC | $30.20 | $48.98 | $97.72 |