- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $32.36
| Facility | TC | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $44.67 / $109.65
| Professional | | $33.11 | $44.67 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $16.22 / $32.36
| Professional | 26 | $10.23 | $16.22 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $30.20 / $58.88
| Professional | TC | $21.88 | $30.20 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $10.72 / $10.72
| Facility | 26 | $8.91 | $10.72 | $10.72 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $26.92 / $26.92
| Facility | TC | $22.39 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $154.88
| Professional | | $74.13 | $107.15 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $32.36 / $45.71
| Professional | 26 | $21.88 | $32.36 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $81.28 / $107.15
| Professional | TC | $57.54 | $81.28 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $45.71 / $112.20
| Facility | 26 | $19.50 | $45.71 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $112.20 / $275.42
| Facility | TC | $39.81 | $112.20 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $83.18 / $134.90
| Professional | | $44.67 | $83.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $23.99 / $38.02
| Professional | 26 | $15.14 | $23.99 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $57.54 / $93.33
| Professional | TC | $29.51 | $57.54 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $44.67 / $87.10
| Facility | 26 | $35.48 | $44.67 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $213.80
| Facility | TC | $87.10 | $109.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $107.15
| Professional | | $64.57 | $64.57 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $18.62 / $30.90
| Professional | 26 | $18.62 | $18.62 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $45.71 / $75.86
| Professional | TC | $45.71 | $45.71 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $64.57 / $275.42
| Professional | | $39.81 | $64.57 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $23.99 / $81.28
| Professional | 26 | $13.18 | $23.99 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $43.65 / $194.98
| Professional | TC | $26.30 | $43.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $95.50 / $316.23
| Professional | | $44.67 | $95.50 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $85.11 / $104.71
| Professional | 26 | $15.49 | $85.11 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $102.33 / $213.80
| Professional | TC | $30.90 | $102.33 | $213.80 |