- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $12.02 / $12.02
| Facility | 26 | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $35.48 / $257.04
| Facility | TC | $22.91 | $35.48 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $43.65 / $63.10
| Professional | | $33.11 | $43.65 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.14 / $20.89
| Professional | 26 | $12.02 | $15.14 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $28.18 / $41.69
| Professional | TC | $20.89 | $28.18 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $42.66 / $57.54
| Professional | | $15.14 | $42.66 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $24.55 / $24.55
| Facility | 26 | $24.55 | $24.55 | $24.55 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $34.67
| Facility | TC | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $40.74 / $63.10
| Professional | | $30.90 | $40.74 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $15.85 / $24.55
| Professional | 26 | $12.30 | $15.85 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $25.70 / $42.66
| Professional | TC | $18.62 | $25.70 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $70.79 / $70.79
| Facility | 26 | $34.67 | $70.79 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $141.25 / $141.25
| Facility | TC | $66.07 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $44.67 / $295.12
| Professional | | $37.15 | $44.67 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $17.38 / $93.33
| Professional | 26 | $14.13 | $17.38 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $27.54 / $204.17
| Professional | TC | $21.88 | $27.54 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $43.65 / $75.86
| Professional | | $36.31 | $43.65 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $16.22 / $26.92
| Professional | 26 | $14.13 | $16.22 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $27.54 / $38.90
| Professional | TC | $21.88 | $27.54 | $38.90 |