- 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
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $58.88 / $263.03
| Professional | | $43.65 | $58.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $12.30 / $44.67
| Professional | 26 | $8.91 | $12.30 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $43.65 / $85.11
| Professional | TC | $33.11 | $43.65 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $63.10 / $107.15
| Professional | | $45.71 | $63.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $16.22 / $25.12
| Professional | 26 | $12.02 | $16.22 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $44.67 / $81.28
| Professional | TC | $33.11 | $44.67 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $32.36 / $60.26
| Professional | | $21.38 | $32.36 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $87.10 / $104.71
| Professional | | $74.13 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $18.62 / $28.18
| Professional | 26 | $15.85 | $18.62 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $69.18 / $77.62
| Professional | TC | $58.88 | $69.18 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $81.28 / $100.00
| Professional | | $50.12 | $81.28 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $18.20 / $25.70
| Professional | 26 | $11.22 | $18.20 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $63.10 / $75.86
| Professional | TC | $39.81 | $63.10 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $58.88 / $97.72
| Professional | | $16.22 | $58.88 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $50.12 / $87.10
| Professional | | $44.67 | $50.12 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $12.59 / $20.89
| Professional | 26 | $10.23 | $12.59 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $39.81 / $66.07
| Professional | TC | $33.88 | $39.81 | $66.07 |