- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $21.88
| Facility | 26 | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $239.88
| Professional | | $74.13 | $107.15 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $22.91 / $45.71
| Professional | 26 | $18.20 | $22.91 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $72.44 / $154.88
| Professional | TC | $54.95 | $72.44 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $109.65 / $194.98
| Professional | | $83.18 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $26.92 / $42.66
| Professional | 26 | $20.89 | $26.92 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $81.28 / $147.91
| Professional | TC | $60.26 | $81.28 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $131.83
| Professional | | $32.36 | $33.11 | $131.83 |
- 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
- $138.04 / $162.18 / $181.97
| Professional | | $138.04 | $162.18 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $33.11 / $45.71
| Professional | 26 | $27.54 | $33.11 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $123.03 / $144.54
| Professional | TC | $109.65 | $123.03 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $151.36 / $181.97
| Professional | | $93.33 | $151.36 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $31.62 / $42.66
| Professional | 26 | $19.50 | $31.62 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $117.49 / $138.04
| Professional | TC | $74.13 | $117.49 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $109.65 / $173.78
| Professional | | $28.84 | $109.65 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $91.20 / $154.88
| Professional | | $77.62 | $91.20 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $21.38 / $35.48
| Professional | 26 | $18.62 | $21.38 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $120.23
| Professional | TC | $57.54 | $72.44 | $120.23 |