- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $63.10 / $87.10
| Facility | 26 | $19.50 | $63.10 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $95.50 / $131.83
| Facility | TC | $63.10 | $95.50 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $45.71 / $131.83
| Professional | | $34.67 | $45.71 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.85 / $53.70
| Professional | 26 | $12.02 | $15.85 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $28.18 / $58.88
| Professional | TC | $20.89 | $28.18 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $58.88 / $87.10
| Professional | | $39.81 | $58.88 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $20.89 / $33.88
| Professional | 26 | $12.30 | $20.89 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $38.90 / $60.26
| Professional | TC | $26.30 | $38.90 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $66.07 / $107.15
| Professional | | $45.71 | $66.07 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $22.39 / $39.81
| Professional | 26 | $16.60 | $22.39 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $42.66 / $74.13
| Professional | TC | $27.54 | $42.66 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $53.70 / $70.79
| Professional | | $43.65 | $53.70 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $19.95 / $24.55
| Professional | 26 | $16.98 | $19.95 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $41.69 / $52.48
| Professional | TC | $28.84 | $41.69 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $22.39 / $74.13
| Professional | | $21.38 | $22.39 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $60.26 / $117.49
| Professional | | $38.02 | $60.26 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $18.62 / $44.67
| Professional | 26 | $13.18 | $18.62 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $38.90 / $69.18
| Professional | TC | $23.99 | $38.90 | $69.18 |