- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $38.90
| Facility | 26 | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $239.88
| Professional | | $87.10 | $117.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $32.36 / $67.61
| Professional | 26 | $22.91 | $32.36 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $81.28 / $173.78
| Professional | TC | $61.66 | $81.28 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $208.93
| Professional | | $107.15 | $151.36 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $40.74 / $57.54
| Professional | 26 | $28.84 | $40.74 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $109.65 / $151.36
| Professional | TC | $77.62 | $109.65 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $257.04
| Professional | | $104.71 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $40.74 / $69.18
| Professional | 26 | $28.18 | $40.74 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $109.65 / $190.55
| Professional | TC | $67.61 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $323.59
| Professional | | $131.83 | $173.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $45.71 / $83.18
| Professional | 26 | $33.88 | $45.71 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $239.88
| Professional | TC | $97.72 | $131.83 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | 26 | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $123.03 / $245.47
| Professional | | $89.13 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $33.11 / $64.57
| Professional | 26 | $23.99 | $33.11 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $181.97
| Professional | TC | $64.57 | $87.10 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $316.23
| Professional | | $95.50 | $147.91 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $43.65 / $95.50
| Professional | 26 | $28.18 | $43.65 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $107.15 / $204.17
| Professional | TC | $72.44 | $107.15 | $204.17 |