- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $15.49 / $15.49
| Facility | 26 | $15.49 | $15.49 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $42.66 / $112.20
| Professional | | $34.67 | $42.66 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $15.14 / $44.67
| Professional | 26 | $12.88 | $15.14 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $47.86
| Professional | TC | $21.88 | $25.70 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $93.33
| Professional | | $41.69 | $58.88 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $21.38 / $33.11
| Professional | 26 | $14.45 | $21.38 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $38.02 / $58.88
| Professional | TC | $23.44 | $38.02 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $51.29 / $89.13
| Professional | | $40.74 | $51.29 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $20.42 / $31.62
| Professional | 26 | $15.49 | $20.42 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $32.36 / $57.54
| Professional | TC | $25.12 | $32.36 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $67.61 / $120.23
| Professional | | $45.71 | $67.61 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $23.99 / $40.74
| Professional | 26 | $17.38 | $23.99 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $52.48 / $79.43
| Professional | TC | $33.11 | $52.48 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $43.65 / $85.11
| Professional | | $34.67 | $43.65 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $16.60 / $31.62
| Professional | 26 | $12.88 | $16.60 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $27.54 / $53.70
| Professional | TC | $21.88 | $27.54 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $54.95 / $114.82
| Professional | | $38.90 | $54.95 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $20.42 / $40.74
| Professional | 26 | $14.79 | $20.42 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $34.67 / $72.44
| Professional | TC | $24.55 | $34.67 | $72.44 |