- 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
- $33.11 / $33.11 / $47.86
| Facility | TC | $33.11 | $33.11 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $46.77 / $56.23
| Professional | | $40.74 | $46.77 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.14 / $19.95
| Professional | 26 | $12.02 | $15.14 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $30.90 / $37.15
| Professional | TC | $25.70 | $30.90 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $134.90
| Professional | | $87.10 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $33.88 / $42.66
| Professional | 26 | $27.54 | $33.88 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $74.13 / $93.33
| Professional | TC | $60.26 | $74.13 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $63.10 / $117.49
| Professional | | $41.69 | $63.10 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $24.55 / $45.71
| Professional | 26 | $16.22 | $24.55 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $38.02 / $72.44
| Professional | TC | $25.70 | $38.02 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $95.50 / $97.72
| Professional | | $89.13 | $95.50 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $31.62 / $38.02
| Professional | 26 | $29.51 | $31.62 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $60.26 / $66.07
| Professional | TC | $57.54 | $60.26 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Professional | 26 | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Professional | TC | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $75.86 / $89.13
| Professional | | $53.70 | $75.86 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $25.12 / $28.18
| Professional | 26 | $17.78 | $25.12 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $52.48 / $60.26
| Professional | TC | $37.15 | $52.48 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $70.79 / $104.71
| Professional | | $46.77 | $70.79 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $26.30 / $40.74
| Professional | 26 | $16.98 | $26.30 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $43.65 / $70.79
| Professional | TC | $28.84 | $43.65 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $91.20 / $91.20
| Professional | | $77.62 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $29.51 / $29.51
| Professional | 26 | $25.12 | $29.51 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $63.10 / $63.10
| Professional | TC | $53.70 | $63.10 | $63.10 |