- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $33.11
| Facility | 26 | $33.11 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $239.88 / $467.74
| Facility | TC | $128.82 | $239.88 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $41.69 / $109.65
| Professional | | $14.45 | $41.69 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.37 / $12.88 / $35.48
| Professional | 26 | $5.37 | $12.88 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $48.98 / $52.48 / $181.97
| Professional | 50 | $48.98 | $52.48 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $67.61
| Professional | 52 | $33.88 | $33.88 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $28.18 / $70.79
| Professional | TC | $19.05 | $28.18 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $47.86 / $72.44
| Professional | | $33.88 | $47.86 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.75 / $8.32 / $13.80
| Professional | 26 | $5.75 | $8.32 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $52.48
| Professional | TC | $28.18 | $37.15 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $56.23 / $91.20
| Professional | | $28.18 | $56.23 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.17 / $10.00 / $14.79
| Professional | 26 | $6.17 | $10.00 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $46.77 / $75.86
| Professional | TC | $21.88 | $46.77 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $38.90 / $52.48
| Professional | | $22.39 | $38.90 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.89 / $8.13 / $10.72
| Professional | 26 | $5.89 | $8.13 | $10.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $32.36 / $42.66
| Professional | TC | $16.98 | $32.36 | $42.66 |