- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $81.28 / $81.28
| Facility | 26 | $16.98 | $81.28 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $851.14 / $954.99
| Facility | TC | $112.20 | $851.14 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $58.88 / $223.87
| Professional | | $43.65 | $58.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $16.22 / $34.67
| Professional | 26 | $13.18 | $16.22 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $41.69 / $91.20
| Professional | TC | $30.90 | $41.69 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $109.65
| Professional | | $50.12 | $66.07 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $20.42 / $30.90
| Professional | 26 | $15.14 | $20.42 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $43.65 / $75.86
| Professional | TC | $33.88 | $43.65 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $33.11 / $74.13
| Professional | | $25.70 | $33.11 | $74.13 |
- 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
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | TC | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $89.13 / $104.71
| Professional | | $75.86 | $89.13 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $22.91 / $33.88
| Professional | 26 | $19.50 | $22.91 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $66.07 / $72.44
| Professional | TC | $54.95 | $66.07 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $83.18 / $102.33
| Professional | | $51.29 | $83.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $22.39 / $30.90
| Professional | 26 | $13.80 | $22.39 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $60.26 / $70.79
| Professional | TC | $38.02 | $60.26 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $56.23 / $93.33
| Professional | | $19.95 | $56.23 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $52.48 / $87.10
| Professional | | $45.71 | $52.48 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $15.49 / $25.12
| Professional | 26 | $13.80 | $15.49 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $37.15 / $61.66
| Professional | TC | $31.62 | $37.15 | $61.66 |