- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $10.96 / $10.96
| Facility | 26 | $10.96 | $10.96 | $10.96 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $85.11 / $95.50
| Facility | TC | $22.91 | $85.11 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $38.02 / $75.86
| Professional | | $30.90 | $38.02 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $12.88 / $27.54
| Professional | 26 | $10.96 | $12.88 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $25.70 / $48.98
| Professional | TC | $19.95 | $25.70 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Professional | | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $10.00
| Professional | 26 | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $109.65
| Facility | TC | $83.18 | $83.18 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $53.70 / $91.20
| Professional | | $39.81 | $53.70 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $25.12 / $39.81
| Professional | 26 | $12.88 | $25.12 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $28.84 / $46.77
| Professional | TC | $25.70 | $28.84 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $47.86 / $75.86
| Professional | | $38.02 | $47.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $17.78 / $30.20
| Professional | 26 | $13.49 | $17.78 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $31.62 / $50.12
| Professional | TC | $23.99 | $31.62 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $46.77 / $79.43
| Professional | | $34.67 | $46.77 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $16.60 / $26.92
| Professional | 26 | $13.18 | $16.60 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $30.20 / $52.48
| Professional | TC | $21.88 | $30.20 | $52.48 |