- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $14.13
| Facility | 26 | $14.13 | $14.13 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $74.13 / $154.88
| Professional | | $57.54 | $74.13 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $19.50 / $33.11
| Professional | 26 | $13.80 | $19.50 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $50.12 / $85.11
| Professional | TC | $42.66 | $50.12 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $147.91 / $181.97
| Professional | | $117.49 | $147.91 | $181.97 |
- 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
- $89.13 / $112.20 / $141.25
| Professional | TC | $89.13 | $112.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $93.33 / $398.11
| Professional | | $58.88 | $93.33 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $26.30 / $151.36
| Professional | 26 | $16.60 | $26.30 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $72.44 / $309.03
| Professional | TC | $45.71 | $72.44 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $128.82 / $131.83
| Professional | | $120.23 | $128.82 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $31.62 / $38.02
| Professional | 26 | $28.84 | $31.62 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $100.00
| Professional | TC | $91.20 | $91.20 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $31.62 / $31.62
| Professional | 26 | $31.62 | $31.62 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | TC | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $120.23
| Professional | | $72.44 | $102.33 | $120.23 |
- 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
- $50.12 / $74.13 / $91.20
| Professional | TC | $50.12 | $74.13 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $107.15 / $154.88
| Professional | | $66.07 | $107.15 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $27.54 / $39.81
| Professional | 26 | $16.98 | $27.54 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $79.43 / $114.82
| Professional | TC | $50.12 | $79.43 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $123.03
| Professional | | $104.71 | $123.03 | $123.03 |
- 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
- $79.43 / $93.33 / $93.33
| Professional | TC | $79.43 | $93.33 | $93.33 |