- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | 26 | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $489.78
| Professional | | $81.28 | $104.71 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $32.36 / $97.72
| Professional | 26 | $22.91 | $32.36 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $72.44 / $141.25
| Professional | TC | $60.26 | $72.44 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $117.49 / $204.17
| Professional | | $81.28 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $33.11 / $61.66
| Professional | 26 | $25.12 | $33.11 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $79.43 / $138.04
| Professional | TC | $58.88 | $79.43 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $144.54
| Professional | | $32.36 | $33.11 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | 26 | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $162.18 / $194.98
| Professional | | $138.04 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $46.77 / $53.70
| Professional | 26 | $38.90 | $46.77 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $117.49 / $144.54
| Professional | TC | $97.72 | $117.49 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $190.55
| Professional | | $89.13 | $147.91 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $44.67 / $61.66
| Professional | 26 | $26.92 | $44.67 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $102.33 / $128.82
| Professional | TC | $63.10 | $102.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $93.33 / $173.78
| Professional | | $36.31 | $93.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $93.33 / $162.18
| Professional | | $81.28 | $93.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $28.84 / $45.71
| Professional | 26 | $22.39 | $28.84 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $67.61 / $120.23
| Professional | TC | $60.26 | $67.61 | $120.23 |