- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $138.04 / $263.03
| Professional | | $109.65 | $138.04 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $30.20 / $93.33
| Professional | 26 | $21.88 | $30.20 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $208.93
| Professional | TC | $85.11 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $263.03
| Professional | | $104.71 | $144.54 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $36.31 / $57.54
| Professional | 26 | $27.54 | $36.31 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $109.65 / $190.55
| Professional | TC | $74.13 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $181.97
| Professional | | $32.36 | $33.11 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | 26 | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $213.80 / $245.47
| Professional | | $186.21 | $213.80 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $43.65 / $61.66
| Professional | 26 | $37.15 | $43.65 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $162.18 / $199.53
| Professional | TC | $138.04 | $162.18 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $199.53 / $257.04
| Professional | | $128.82 | $199.53 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $42.66 / $64.57
| Professional | 26 | $26.30 | $42.66 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $177.83
| Professional | TC | $102.33 | $154.88 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $144.54 / $245.47
| Professional | | $38.02 | $144.54 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $120.23 / $204.17
| Professional | | $102.33 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $28.18 / $46.77
| Professional | 26 | $23.44 | $28.18 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $93.33 / $154.88
| Professional | TC | $74.13 | $93.33 | $154.88 |