- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | 26 | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $79.43 / $218.78
| Professional | | $53.70 | $79.43 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $23.44 / $67.61
| Professional | 26 | $12.30 | $23.44 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $61.66 / $89.13
| Professional | TC | $36.31 | $61.66 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $81.28 / $81.28
| Professional | | $19.50 | $81.28 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $23.99
| Facility | 26 | $19.50 | $19.50 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $81.28 / $123.03
| Professional | | $43.65 | $81.28 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $20.89 / $34.67
| Professional | 26 | $12.88 | $20.89 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $54.95 / $93.33
| Professional | TC | $32.36 | $54.95 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $89.13 / $134.90
| Professional | | $81.28 | $89.13 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $23.99
| Facility | 26 | $19.50 | $19.50 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $114.82 / $138.04
| Professional | | $69.18 | $114.82 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $21.38 / $29.51
| Professional | 26 | $12.88 | $21.38 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $91.20
| Professional | TC | $37.15 | $56.23 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $53.70 / $95.50
| Professional | | $48.98 | $53.70 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $16.22 / $85.11
| Professional | 26 | $13.49 | $16.22 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $37.15 / $83.18
| Professional | TC | $33.11 | $37.15 | $83.18 |