- 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
- $91.20 / $117.49 / $251.19
| Professional | | $91.20 | $117.49 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $30.90 / $75.86
| Professional | 26 | $25.12 | $30.90 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $81.28 / $151.36
| Professional | TC | $64.57 | $81.28 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $141.25 / $218.78
| Professional | | $104.71 | $141.25 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $40.74 / $61.66
| Professional | 26 | $30.20 | $40.74 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $158.49
| Professional | TC | $72.44 | $97.72 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $173.78
| Professional | | $32.36 | $33.11 | $173.78 |
- 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
- $147.91 / $173.78 / $213.80
| Professional | | $147.91 | $173.78 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $48.98 / $58.88
| Professional | 26 | $38.90 | $48.98 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $128.82 / $158.49
| Professional | TC | $107.15 | $128.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $162.18 / $213.80
| Professional | | $107.15 | $162.18 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $44.67 / $61.66
| Professional | 26 | $28.18 | $44.67 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $151.36
| Professional | TC | $77.62 | $117.49 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $107.15 / $186.21
| Professional | | $39.81 | $107.15 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $181.97
| Professional | | $93.33 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $30.20 / $50.12
| Professional | 26 | $28.84 | $30.20 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $79.43 / $131.83
| Professional | TC | $74.13 | $79.43 | $131.83 |