- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $12.30 / $12.30
| Facility | 26 | $12.30 | $12.30 | $12.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $60.26 / $234.42
| Professional | | $42.66 | $60.26 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $16.98 / $52.48
| Professional | 26 | $12.02 | $16.98 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $40.74 / $112.20
| Professional | TC | $30.20 | $40.74 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $52.48 / $61.66
| Professional | | $14.79 | $52.48 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $14.45 / $16.98
| Professional | 26 | $12.59 | $14.45 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $46.77 / $50.12
| Professional | TC | $38.90 | $46.77 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Facility | 26 | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $63.10 / $107.15
| Professional | | $42.66 | $63.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $16.60 / $30.20
| Professional | 26 | $10.96 | $16.60 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $45.71 / $83.18
| Professional | TC | $31.62 | $45.71 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $64.57 / $87.10
| Professional | | $57.54 | $64.57 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $16.60 / $22.39
| Professional | 26 | $14.79 | $16.60 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $48.98 / $64.57
| Professional | TC | $42.66 | $48.98 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $58.88 / $114.82
| Professional | | $43.65 | $58.88 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $15.85 / $31.62
| Professional | 26 | $11.75 | $15.85 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $42.66 / $77.62
| Professional | TC | $32.36 | $42.66 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $63.10 / $85.11
| Professional | | $48.98 | $63.10 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $15.85 / $21.88
| Professional | 26 | $12.30 | $15.85 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $46.77 / $63.10
| Professional | TC | $36.31 | $46.77 | $63.10 |