- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Facility | 26 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $85.11 / $281.84
| Professional | | $45.71 | $85.11 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $39.81 / $87.10
| Professional | 26 | $19.05 | $39.81 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $46.77 / $72.44
| Professional | TC | $19.95 | $46.77 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $77.62 / $77.62
| Professional | | $36.31 | $77.62 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $44.67
| Facility | 26 | $36.31 | $36.31 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $85.11 / $128.82
| Professional | | $57.54 | $85.11 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $36.31 / $54.95
| Professional | 26 | $18.62 | $36.31 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $46.77 / $95.50
| Professional | TC | $28.18 | $46.77 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $85.11 / $169.82
| Professional | | $81.28 | $85.11 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $44.67
| Facility | 26 | $36.31 | $36.31 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $128.82
| Professional | | $64.57 | $87.10 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $36.31 / $45.71
| Professional | 26 | $23.44 | $36.31 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $41.69 / $69.18
| Professional | TC | $28.18 | $41.69 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $75.86 / $117.49
| Professional | | $48.98 | $75.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $25.70 / $79.43
| Professional | 26 | $19.95 | $25.70 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $35.48 / $85.11
| Professional | TC | $23.99 | $35.48 | $85.11 |