- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Facility | 26 | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $251.19 / $275.42
| Facility | TC | $33.11 | $251.19 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $51.29 / $245.47
| Professional | | $38.02 | $51.29 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $17.38 / $79.43
| Professional | 26 | $12.02 | $17.38 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $33.11 / $72.44
| Professional | TC | $25.70 | $33.11 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $61.66 / $93.33
| Professional | | $46.77 | $61.66 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $21.38 / $33.11
| Professional | 26 | $14.79 | $21.38 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $38.90 / $63.10
| Professional | TC | $28.18 | $38.90 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $33.11 / $91.20
| Professional | | $29.51 | $33.11 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | TC | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $102.33
| Professional | | $63.10 | $74.13 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $21.88 / $38.02
| Professional | 26 | $18.62 | $21.88 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $51.29 / $63.10
| Professional | TC | $43.65 | $51.29 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $69.18 / $89.13
| Professional | | $41.69 | $69.18 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $21.38 / $33.11
| Professional | 26 | $12.88 | $21.38 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $47.86 / $57.54
| Professional | TC | $28.84 | $47.86 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $46.77 / $85.11
| Professional | | $19.05 | $46.77 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $47.86 / $79.43
| Professional | | $42.66 | $47.86 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $16.60 / $27.54
| Professional | 26 | $13.80 | $16.60 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $30.90 / $53.70
| Professional | TC | $28.18 | $30.90 | $53.70 |