- 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
- $30.90 / $30.90 / $44.67
| Facility | TC | $30.90 | $30.90 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $42.66 / $50.12
| Professional | | $38.02 | $42.66 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $12.88 / $25.12
| Professional | 26 | $12.02 | $12.88 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $28.84 / $42.66
| Professional | TC | $25.70 | $28.84 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $100.00 / $125.89
| Professional | | $79.43 | $100.00 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $30.20 / $38.02
| Professional | 26 | $23.99 | $30.20 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $69.18 / $87.10
| Professional | TC | $56.23 | $69.18 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $109.65
| Professional | | $38.90 | $58.88 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $21.38 / $39.81
| Professional | 26 | $14.13 | $21.38 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $37.15 / $70.79
| Professional | TC | $25.12 | $37.15 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $89.13 / $89.13
| Professional | | $83.18 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $27.54 / $33.11
| Professional | 26 | $26.30 | $27.54 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $61.66
| Professional | TC | $56.23 | $56.23 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Professional | 26 | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Professional | TC | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $69.18 / $81.28
| Professional | | $50.12 | $69.18 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $21.88 / $25.12
| Professional | 26 | $15.85 | $21.88 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $48.98 / $56.23
| Professional | TC | $34.67 | $48.98 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $66.07 / $97.72
| Professional | | $43.65 | $66.07 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $22.91 / $35.48
| Professional | 26 | $15.49 | $22.91 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $42.66 / $66.07
| Professional | TC | $27.54 | $42.66 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $85.11 / $85.11
| Professional | | $72.44 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $26.30 / $26.30
| Professional | 26 | $22.39 | $26.30 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $58.88
| Professional | TC | $50.12 | $58.88 | $58.88 |