- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $36.31
| Facility | 26 | $36.31 | $36.31 | $36.31 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $346.74 / $346.74
| Facility | TC | $263.03 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $64.57 / $186.21
| Professional | | $34.67 | $64.57 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $18.20 / $50.12
| Professional | 26 | $10.47 | $18.20 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $38.90 / $70.79
| Professional | TC | $23.99 | $38.90 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $57.54 / $57.54
| Professional | | $16.98 | $57.54 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $20.89
| Facility | 26 | $16.98 | $16.98 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $51.29
| Facility | TC | $40.74 | $40.74 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $54.95 / $95.50
| Professional | | $26.92 | $54.95 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.12 / $16.98 / $30.90
| Professional | 26 | $9.12 | $16.98 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.78 / $35.48 / $64.57
| Professional | TC | $17.78 | $35.48 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $63.10 / $95.50
| Professional | | $53.70 | $63.10 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $20.89
| Facility | 26 | $16.98 | $16.98 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $51.29
| Facility | TC | $40.74 | $40.74 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $81.28 / $97.72
| Professional | | $46.77 | $81.28 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $16.98 / $25.12
| Professional | 26 | $11.48 | $16.98 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $37.15 / $60.26
| Professional | TC | $25.12 | $37.15 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $36.31 / $72.44
| Professional | | $33.88 | $36.31 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $12.59 / $87.10
| Professional | 26 | $11.75 | $12.59 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $24.55 / $50.12
| Professional | TC | $21.88 | $24.55 | $50.12 |