- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $26.30 / $26.30
| Facility | 26 | $26.30 | $26.30 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $75.86 / $186.21
| Professional | | $52.48 | $75.86 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $16.98 / $43.65
| Professional | 26 | $12.88 | $16.98 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $56.23 / $154.88
| Professional | TC | $40.74 | $56.23 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $165.96
| Professional | | $79.43 | $125.89 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $26.30 / $38.02
| Professional | 26 | $16.98 | $26.30 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $97.72 / $128.82
| Professional | TC | $63.10 | $97.72 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $117.49 / $218.78
| Professional | | $81.28 | $117.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $26.92 / $47.86
| Professional | 26 | $17.78 | $26.92 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $93.33 / $186.21
| Professional | TC | $61.66 | $93.33 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $144.54 / $218.78
| Professional | | $93.33 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $30.90 / $45.71
| Professional | 26 | $19.50 | $30.90 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $112.20 / $165.96
| Professional | TC | $72.44 | $112.20 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $120.23 / $275.42
| Professional | | $83.18 | $120.23 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $26.30 / $52.48
| Professional | 26 | $18.62 | $26.30 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $177.83
| Professional | TC | $64.57 | $87.10 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $14.13 / $17.38
| Facility | 26 | $12.88 | $14.13 | $17.38 |