- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $38.90 / $38.90
| Facility | 26 | $19.05 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $128.82
| Professional | | $58.88 | $77.62 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $16.98 / $26.92
| Professional | 26 | $12.88 | $16.98 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $60.26 / $95.50
| Professional | TC | $44.67 | $60.26 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $18.62 / $18.62
| Professional | 26 | $18.62 | $18.62 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $147.91
| Professional | | $57.54 | $83.18 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $21.88 / $33.88
| Professional | 26 | $14.79 | $21.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $66.07 / $120.23
| Professional | TC | $42.66 | $66.07 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $77.62
| Facility | 26 | $40.74 | $40.74 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $512.86
| Professional | | $67.61 | $87.10 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $21.38 / $109.65
| Professional | 26 | $17.78 | $21.38 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $67.61 / $398.11
| Professional | TC | $50.12 | $67.61 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $79.43 / $134.90
| Professional | | $67.61 | $79.43 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $19.05 / $31.62
| Professional | 26 | $17.78 | $19.05 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $60.26 / $104.71
| Professional | TC | $50.12 | $60.26 | $104.71 |