- 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
- $64.57 / $81.28 / $204.17
| Professional | | $64.57 | $81.28 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $17.78 / $43.65
| Professional | 26 | $14.13 | $17.78 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $61.66 / $120.23
| Professional | TC | $45.71 | $61.66 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $91.20 / $162.18
| Professional | | $69.18 | $91.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $23.44 / $36.31
| Professional | 26 | $18.20 | $23.44 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $123.03
| Professional | TC | $50.12 | $66.07 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $112.20
| Professional | | $32.36 | $33.11 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $131.83 / $144.54
| Professional | | $109.65 | $131.83 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $28.18 / $38.90
| Professional | 26 | $23.99 | $28.18 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $114.82
| Professional | TC | $87.10 | $102.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $123.03 / $154.88
| Professional | | $75.86 | $123.03 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $26.92 / $38.02
| Professional | 26 | $16.60 | $26.92 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $95.50 / $117.49
| Professional | TC | $58.88 | $95.50 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $89.13 / $141.25
| Professional | | $24.55 | $89.13 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $77.62 / $131.83
| Professional | | $64.57 | $77.62 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $18.62 / $30.90
| Professional | 26 | $15.85 | $18.62 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $61.66 / $97.72
| Professional | TC | $47.86 | $61.66 | $97.72 |