- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $32.36 / $97.72
| Facility | 26 | $12.88 | $32.36 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $97.72 / $229.09
| Professional | | $57.54 | $97.72 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $23.99 / $44.67
| Professional | 26 | $12.88 | $23.99 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $52.48 / $125.89
| Professional | TC | $38.90 | $52.48 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $239.88
| Professional | | $57.54 | $79.43 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $15.85 / $19.05
| Professional | 26 | $14.13 | $15.85 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $64.57 / $64.57
| Professional | TC | $57.54 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $74.13 / $173.78
| Professional | | $56.23 | $74.13 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $18.62 / $39.81
| Professional | 26 | $12.88 | $18.62 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $56.23 / $138.04
| Professional | TC | $42.66 | $56.23 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $83.18 / $165.96
| Professional | | $70.79 | $83.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $16.60 / $33.11
| Professional | 26 | $13.80 | $16.60 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $134.90
| Professional | TC | $56.23 | $67.61 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $95.50 / $371.54
| Professional | | $57.54 | $95.50 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $91.20 / $95.50
| Professional | 26 | $14.79 | $91.20 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $95.50 / $346.74
| Professional | TC | $42.66 | $95.50 | $346.74 |