- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | 26 | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $524.81
| Professional | | $87.10 | $120.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $32.36 / $87.10
| Professional | 26 | $23.99 | $32.36 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $75.86 / $158.49
| Professional | TC | $64.57 | $75.86 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $218.78
| Professional | | $97.72 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $56.23
| Professional | 26 | $28.18 | $37.15 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $91.20 / $162.18
| Professional | TC | $67.61 | $91.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $204.17
| Professional | | $32.36 | $33.11 | $204.17 |
- 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
- $151.36 / $177.83 / $218.78
| Professional | | $151.36 | $177.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $43.65 / $53.70
| Professional | 26 | $36.31 | $43.65 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $165.96
| Professional | TC | $114.82 | $134.90 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $162.18 / $239.88
| Professional | | $100.00 | $162.18 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $40.74 / $61.66
| Professional | 26 | $25.12 | $40.74 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $123.03 / $177.83
| Professional | TC | $75.86 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $114.82 / $173.78
| Professional | | $35.48 | $114.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $114.82 / $190.55
| Professional | | $93.33 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $29.51 / $46.77
| Professional | 26 | $25.70 | $29.51 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $144.54
| Professional | TC | $67.61 | $87.10 | $144.54 |