- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | 26 | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $77.62 / $204.17
| Professional | | $53.70 | $77.62 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $30.90 / $83.18
| Professional | 26 | $19.05 | $30.90 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $39.81 / $97.72
| Professional | TC | $22.91 | $39.81 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $112.20 / $234.42
| Professional | | $74.13 | $112.20 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $48.98 / $107.15
| Professional | 26 | $30.90 | $48.98 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $69.18 / $141.25
| Professional | TC | $42.66 | $69.18 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | 26 | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $190.55 / $309.03
| Professional | | $89.13 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $91.20 / $147.91
| Professional | 26 | $41.69 | $91.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $104.71 / $158.49
| Professional | TC | $54.95 | $104.71 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $416.87
| Professional | | $275.42 | $275.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $177.83
| Professional | 26 | $112.20 | $125.89 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $158.49 / $223.87
| Professional | TC | $147.91 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $123.03 / $208.93
| Professional | | $69.18 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $42.66 / $107.15
| Professional | 26 | $28.18 | $42.66 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $35.48 / $53.70 / $141.25
| Professional | TC | $35.48 | $53.70 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $173.78 / $354.81
| Professional | | $75.86 | $173.78 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $85.11 / $181.97
| Professional | 26 | $30.20 | $85.11 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $97.72 / $169.82
| Professional | TC | $44.67 | $97.72 | $169.82 |