- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $15.14
| Facility | 26 | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $173.78 / $186.21
| Facility | TC | $25.70 | $173.78 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $42.66 / $223.87
| Professional | | $34.67 | $42.66 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $14.13 / $30.90
| Professional | 26 | $10.96 | $14.13 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $28.84 / $57.54
| Professional | TC | $22.91 | $28.84 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $52.48 / $87.10
| Professional | | $40.74 | $52.48 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $19.05 / $28.84
| Professional | 26 | $14.13 | $19.05 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $33.11 / $56.23
| Professional | TC | $25.12 | $33.11 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $83.18
| Professional | | $32.36 | $33.11 | $83.18 |
- 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
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | TC | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $69.18 / $81.28
| Professional | | $58.88 | $69.18 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $21.38 / $28.84
| Professional | 26 | $18.20 | $21.38 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $46.77 / $54.95
| Professional | TC | $40.74 | $46.77 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $64.57 / $81.28
| Professional | | $38.90 | $64.57 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $20.89 / $29.51
| Professional | 26 | $12.30 | $20.89 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $39.81 / $52.48
| Professional | TC | $26.92 | $39.81 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $40.74 / $69.18
| Professional | | $18.62 | $40.74 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $41.69 / $69.18
| Professional | | $36.31 | $41.69 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $14.45 / $23.44
| Professional | 26 | $12.88 | $14.45 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $27.54 / $45.71
| Professional | TC | $23.99 | $27.54 | $45.71 |