- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $8.91 / $8.91
| Facility | 26 | $8.91 | $8.91 | $8.91 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $19.95
| Facility | TC | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $29.51 / $147.91
| Professional | | $19.95 | $29.51 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $8.71 / $30.90
| Professional | 26 | $7.08 | $8.71 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $20.89 / $50.12
| Professional | TC | $16.98 | $20.89 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $37.15 / $61.66
| Professional | | $28.84 | $37.15 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.51 / $11.22 / $17.38
| Professional | 26 | $8.51 | $11.22 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $25.12 / $42.66
| Professional | TC | $19.50 | $25.12 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $33.11 / $50.12
| Professional | | $14.45 | $33.11 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | TC | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $48.98 / $58.88
| Professional | | $40.74 | $48.98 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $13.18 / $18.62
| Professional | 26 | $11.22 | $13.18 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $35.48 / $40.74
| Professional | TC | $29.51 | $35.48 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $45.71 / $57.54
| Professional | | $28.18 | $45.71 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.76 / $12.59 / $17.38
| Professional | 26 | $7.76 | $12.59 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $32.36 / $39.81
| Professional | TC | $19.95 | $32.36 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $30.20 / $50.12
| Professional | | $11.48 | $30.20 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $29.51 / $48.98
| Professional | | $25.12 | $29.51 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.76 / $8.71 / $14.45
| Professional | 26 | $7.76 | $8.71 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $20.89 / $34.67
| Professional | TC | $18.20 | $20.89 | $34.67 |