- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $26.92
| Facility | 26 | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $112.20 / $173.78
| Professional | | $85.11 | $112.20 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $85.11
| Professional | 26 | $26.92 | $38.90 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $120.23
| Professional | TC | $58.88 | $77.62 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $104.71 / $144.54
| Professional | | $33.11 | $104.71 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $151.36
| Professional | | $81.28 | $104.71 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $33.88 / $54.95
| Professional | 26 | $26.92 | $33.88 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $112.20
| Professional | TC | $53.70 | $67.61 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $151.36 / $151.36
| Facility | 26 | $77.62 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $114.82 / $724.44
| Professional | | $93.33 | $114.82 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $37.15 / $208.93
| Professional | 26 | $30.20 | $37.15 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $77.62 / $524.81
| Professional | TC | $61.66 | $77.62 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $177.83
| Professional | | $89.13 | $104.71 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $34.67 / $58.88
| Professional | 26 | $30.20 | $34.67 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $70.79 / $104.71
| Professional | TC | $60.26 | $70.79 | $104.71 |