- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $33.11
| Facility | 26 | $33.11 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $144.54
| Professional | | $57.54 | $70.79 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $30.90 / $67.61
| Professional | 26 | $25.12 | $30.90 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $66.07 / $213.80 / $257.04
| Professional | 50 | $66.07 | $213.80 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $43.65 / $72.44
| Professional | TC | $30.20 | $43.65 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $144.54
| Professional | | $72.44 | $97.72 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $39.81 / $64.57
| Professional | 26 | $29.51 | $39.81 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $54.95 / $79.43
| Professional | TC | $38.90 | $54.95 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $70.79
| Professional | | $32.36 | $33.11 | $70.79 |
- 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
- $95.50 / $128.82 / $173.78
| Professional | | $95.50 | $128.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $54.95 / $295.12
| Professional | 26 | $41.69 | $54.95 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $104.71
| Professional | TC | $53.70 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $104.71 / $141.25
| Professional | | $66.07 | $104.71 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $47.86 / $67.61
| Professional | 26 | $29.51 | $47.86 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $57.54 / $74.13
| Professional | TC | $37.15 | $57.54 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $60.26 / $120.23
| Professional | | $37.15 | $60.26 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $77.62 / $120.23
| Professional | | $64.57 | $77.62 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $31.62 / $52.48
| Professional | 26 | $27.54 | $31.62 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $43.65 / $66.07
| Professional | TC | $34.67 | $43.65 | $66.07 |