- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $19.50
| Facility | 26 | $19.50 | $19.50 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $47.86 / $107.15
| Professional | | $28.84 | $47.86 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.85 / $41.69
| Professional | 26 | $12.02 | $15.85 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $30.20 / $60.26
| Professional | TC | $15.85 | $30.20 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $60.26 / $89.13
| Professional | | $41.69 | $60.26 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $22.39 / $30.90
| Professional | 26 | $14.45 | $22.39 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $37.15 / $58.88
| Professional | TC | $26.92 | $37.15 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $61.66 / $117.49
| Professional | | $46.77 | $61.66 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $21.88 / $46.77
| Professional | 26 | $14.79 | $21.88 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $43.65 / $77.62
| Professional | TC | $28.18 | $43.65 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $72.44 / $134.90
| Professional | | $53.70 | $72.44 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $24.55 / $46.77
| Professional | 26 | $19.95 | $24.55 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $46.77 / $89.13
| Professional | TC | $37.15 | $46.77 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $47.86 / $87.10
| Professional | | $38.02 | $47.86 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $16.60 / $32.36
| Professional | 26 | $12.88 | $16.60 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $32.36 / $54.95
| Professional | TC | $23.44 | $32.36 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $63.10 / $134.90
| Professional | | $46.77 | $63.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $23.99 / $64.57
| Professional | 26 | $16.98 | $23.99 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $67.61
| Professional | TC | $26.92 | $38.90 | $67.61 |