- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $52.48 / $213.80
| Professional | | $33.88 | $52.48 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $12.02 / $40.74
| Professional | 26 | $8.91 | $12.02 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $36.31 / $67.61
| Professional | TC | $25.12 | $36.31 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $56.23 / $87.10
| Professional | | $43.65 | $56.23 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $15.14 / $23.44
| Professional | 26 | $10.96 | $15.14 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $41.69 / $61.66
| Professional | TC | $30.90 | $41.69 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $33.11 / $72.44
| Professional | | $21.38 | $33.11 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $87.10
| Professional | | $56.23 | $67.61 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $17.78 / $26.92
| Professional | 26 | $14.79 | $17.78 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $50.12 / $60.26
| Professional | TC | $41.69 | $50.12 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $91.20
| Professional | | $39.81 | $61.66 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $16.98 / $23.44
| Professional | 26 | $10.47 | $16.98 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $45.71 / $63.10
| Professional | TC | $29.51 | $45.71 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $44.67 / $81.28
| Professional | | $15.14 | $44.67 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $44.67 / $74.13
| Professional | | $38.02 | $44.67 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.55 / $11.48 / $19.50
| Professional | 26 | $9.55 | $11.48 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $33.11 / $53.70
| Professional | TC | $26.92 | $33.11 | $53.70 |