- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | 26 | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $177.83 / $426.58
| Professional | | $104.71 | $177.83 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $36.31 / $77.62
| Professional | 26 | $23.99 | $36.31 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $125.89 / $269.15
| Professional | TC | $69.18 | $125.89 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Professional | 26 | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $295.12
| Professional | | $120.23 | $213.80 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $34.67 / $53.70
| Professional | 26 | $31.62 | $34.67 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $169.82 / $245.47
| Professional | TC | $89.13 | $169.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $275.42 / $512.86
| Professional | | $138.04 | $275.42 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $53.70 / $87.10
| Professional | 26 | $33.88 | $53.70 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $229.09 / $426.58
| Professional | TC | $93.33 | $229.09 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $218.78 / $331.13
| Professional | | $141.25 | $218.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $85.11
| Professional | 26 | $37.15 | $56.23 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $234.42
| Professional | TC | $104.71 | $158.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $436.52
| Professional | | $131.83 | $199.53 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $44.67 / $89.13
| Professional | 26 | $34.67 | $44.67 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $363.08
| Professional | TC | $102.33 | $158.49 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $29.51 / $32.36
| Facility | 26 | $22.39 | $29.51 | $32.36 |