- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.12 / $9.12 / $9.12
| Facility | 26 | $9.12 | $9.12 | $9.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $32.36 / $107.15
| Professional | | $21.88 | $32.36 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.63 / $3.80 / $11.48
| Professional | 26 | $2.63 | $3.80 | $11.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $28.84 / $85.11
| Professional | TC | $18.20 | $28.84 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $48.98 / $147.91
| Professional | | $25.70 | $48.98 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.16 / $5.50 / $10.47
| Professional | 26 | $3.16 | $5.50 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $43.65 / $141.25
| Professional | TC | $22.91 | $43.65 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.12 / $9.12 / $9.12
| Facility | 26 | $9.12 | $9.12 | $9.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $63.10 / $107.15
| Professional | | $32.36 | $63.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.24 / $9.77 / $17.38
| Professional | 26 | $3.24 | $9.77 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $54.95 / $89.13
| Professional | TC | $24.55 | $54.95 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $128.82
| Professional | | $95.50 | $95.50 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $12.02 / $16.60
| Professional | 26 | $10.96 | $12.02 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $112.20
| Professional | TC | $69.18 | $83.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $46.77 / $72.44
| Professional | | $25.12 | $46.77 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.02 / $4.37 / $11.48
| Professional | 26 | $3.02 | $4.37 | $11.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $30.20 / $77.62
| Professional | TC | $20.42 | $30.20 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $58.88 / $109.65
| Professional | | $44.67 | $58.88 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.01 / $9.12 / $13.80
| Professional | 26 | $5.01 | $9.12 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $35.48 / $48.98 / $104.71
| Professional | TC | $35.48 | $48.98 | $104.71 |