- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Facility | 26 | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $66.07 / $263.03
| Professional | | $51.29 | $66.07 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $17.38 / $45.71
| Professional | 26 | $12.88 | $17.38 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $45.71 / $91.20
| Professional | TC | $37.15 | $45.71 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $125.89
| Professional | | $58.88 | $75.86 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $21.38 / $33.11
| Professional | 26 | $15.85 | $21.38 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $52.48 / $89.13
| Professional | TC | $40.74 | $52.48 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $93.33
| Professional | | $32.36 | $33.11 | $93.33 |
- 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
- $87.10 / $102.33 / $120.23
| Professional | | $87.10 | $102.33 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $24.55 / $36.31
| Professional | 26 | $20.89 | $24.55 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $77.62 / $87.10
| Professional | TC | $66.07 | $77.62 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $95.50 / $114.82
| Professional | | $58.88 | $95.50 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $23.99 / $32.36
| Professional | 26 | $14.45 | $23.99 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $70.79 / $83.18
| Professional | TC | $43.65 | $70.79 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $66.07 / $107.15
| Professional | | $21.38 | $66.07 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $60.26 / $100.00
| Professional | | $52.48 | $60.26 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $16.60 / $26.92
| Professional | 26 | $14.79 | $16.60 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $43.65 / $72.44
| Professional | TC | $38.02 | $43.65 | $72.44 |