- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $16.22
| Facility | 26 | $16.22 | $16.22 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $51.29 / $104.71
| Professional | | $32.36 | $51.29 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.77 / $16.98 / $33.11
| Professional | 26 | $9.77 | $16.98 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $31.62 / $61.66
| Professional | TC | $20.89 | $31.62 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $39.81 / $53.70
| Professional | | $31.62 | $39.81 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $14.13 / $15.85
| Professional | 26 | $9.33 | $14.13 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $57.54 / $72.44
| Professional | | $39.81 | $57.54 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $17.38 / $22.39
| Professional | 26 | $12.30 | $17.38 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $39.81 / $51.29
| Professional | TC | $27.54 | $39.81 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $11.75 / $11.75
| Facility | 26 | $11.75 | $11.75 | $11.75 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $45.71 / $93.33
| Professional | | $28.84 | $45.71 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $14.79 / $30.90
| Professional | 26 | $9.33 | $14.79 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $35.48 / $74.13
| Professional | TC | $22.91 | $35.48 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $38.90 / $74.13
| Professional | | $28.84 | $38.90 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $12.59 / $69.18
| Professional | 26 | $8.91 | $12.59 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $26.92 / $38.90
| Professional | TC | $19.05 | $26.92 | $38.90 |