- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $12.59 / $12.59
| Facility | 26 | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $169.82 / $177.83
| Facility | TC | $56.23 | $169.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $26.92 / $46.77
| Professional | | $20.89 | $26.92 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $7.94 / $23.99
| Professional | 26 | $6.03 | $7.94 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $19.05 / $34.67
| Professional | TC | $15.14 | $19.05 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $46.77 / $61.66
| Professional | | $29.51 | $46.77 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $12.59 / $18.20
| Professional | 26 | $7.94 | $12.59 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $33.88 / $44.67
| Professional | TC | $21.38 | $33.88 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $45.71 / $81.28
| Professional | | $30.20 | $45.71 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.51 / $12.88 / $22.91
| Professional | 26 | $8.51 | $12.88 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $33.11 / $64.57
| Professional | TC | $21.38 | $33.11 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $53.70 / $81.28
| Professional | | $33.88 | $53.70 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $14.45 / $20.89
| Professional | 26 | $9.33 | $14.45 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $39.81 / $58.88
| Professional | TC | $24.55 | $39.81 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $44.67 / $95.50
| Professional | | $32.36 | $44.67 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.71 / $12.59 / $24.55
| Professional | 26 | $8.71 | $12.59 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $31.62 / $60.26
| Professional | TC | $22.91 | $31.62 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $6.61 / $7.94
| Facility | 26 | $6.03 | $6.61 | $7.94 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $18.62 / $21.38
| Facility | TC | $16.98 | $18.62 | $21.38 |