- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $19.05
| Facility | 26 | $19.05 | $19.05 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $58.88 / $128.82
| Professional | | $44.67 | $58.88 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $20.89 / $38.90
| Professional | 26 | $15.85 | $20.89 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $39.81 / $89.13
| Professional | TC | $28.84 | $39.81 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $72.44
| Professional | | $15.85 | $15.85 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $10.96 / $38.90
| Professional | 26 | $10.96 | $10.96 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $4.79 / $5.37 / $33.11
| Professional | TC | $4.79 | $5.37 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $32.36 / $79.43
| Professional | | $27.54 | $32.36 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $28.18 / $40.74
| Facility | 26 | $6.03 | $28.18 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $72.44 / $389.05
| Professional | | $34.67 | $72.44 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $30.20 / $128.82
| Professional | 26 | $11.75 | $30.20 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $32.36 / $275.42
| Professional | TC | $20.89 | $32.36 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $66.07 / $109.65
| Professional | | $40.74 | $66.07 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $26.30 / $51.29
| Professional | 26 | $18.62 | $26.30 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $39.81 / $67.61
| Professional | TC | $20.89 | $39.81 | $67.61 |