- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Facility | 26 | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $109.65 / $223.87
| Professional | | $54.95 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $23.99 / $48.98
| Professional | 26 | $15.85 | $23.99 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $89.13 / $162.18
| Professional | TC | $52.48 | $89.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $125.89 / $177.83
| Professional | | $72.44 | $125.89 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $23.44 / $33.88
| Professional | 26 | $12.88 | $23.44 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $102.33 / $131.83
| Professional | TC | $60.26 | $102.33 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $134.90 / $257.04
| Professional | | $91.20 | $134.90 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $25.70 / $44.67
| Professional | 26 | $17.78 | $25.70 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $112.20 / $213.80
| Professional | TC | $72.44 | $112.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $281.84
| Professional | | $120.23 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $26.92 / $50.12
| Professional | 26 | $21.38 | $26.92 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $234.42
| Professional | TC | $97.72 | $123.03 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $123.03 / $218.78
| Professional | | $89.13 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $22.39 / $39.81
| Professional | 26 | $16.22 | $22.39 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $181.97
| Professional | TC | $72.44 | $97.72 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $123.03 / $251.19
| Professional | | $91.20 | $123.03 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $26.92 / $69.18
| Professional | 26 | $18.20 | $26.92 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $100.00 / $177.83
| Professional | TC | $69.18 | $100.00 | $177.83 |