- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Facility | 26 | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $107.15 / $281.84
| Professional | | $64.57 | $107.15 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.91 / $66.07
| Professional | 26 | $14.13 | $22.91 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $87.10 / $229.09
| Professional | TC | $52.48 | $87.10 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $162.18 / $316.23
| Professional | | $89.13 | $162.18 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $30.20 / $61.66
| Professional | 26 | $18.62 | $30.20 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $128.82 / $257.04
| Professional | TC | $70.79 | $128.82 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Facility | 26 | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $245.47 / $478.63
| Professional | | $109.65 | $245.47 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $51.29 / $109.65
| Professional | 26 | $19.50 | $51.29 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $204.17 / $371.54
| Professional | TC | $87.10 | $204.17 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $398.11 / $588.84
| Professional | | $389.05 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $72.44 / $120.23
| Professional | 26 | $66.07 | $72.44 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $331.13 / $489.78
| Professional | TC | $239.88 | $331.13 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $245.47 / $309.03
| Professional | | $93.33 | $245.47 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $25.12 / $64.57
| Professional | 26 | $15.14 | $25.12 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $95.50 / $257.04
| Professional | TC | $67.61 | $95.50 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $229.09 / $457.09
| Professional | | $120.23 | $229.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $52.48 / $104.71
| Professional | 26 | $21.38 | $52.48 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $173.78 / $354.81
| Professional | TC | $93.33 | $173.78 | $354.81 |