- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $891.25 / $891.25
| Facility | 26 | $20.89 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $114.82 / $549.54
| Professional | | $85.11 | $114.82 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $20.89 / $67.61
| Professional | 26 | $15.14 | $20.89 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $93.33 / $165.96
| Professional | TC | $70.79 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $128.82 / $199.53
| Professional | | $87.10 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $25.70 / $38.90
| Professional | 26 | $17.78 | $25.70 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $158.49
| Professional | TC | $64.57 | $95.50 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $117.49
| Professional | | $32.36 | $33.11 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $190.55
| Professional | | $134.90 | $154.88 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $30.20 / $40.74
| Professional | 26 | $24.55 | $30.20 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $158.49
| Professional | TC | $104.71 | $123.03 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $147.91 / $213.80
| Professional | | $93.33 | $147.91 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $28.84 / $41.69
| Professional | 26 | $17.38 | $28.84 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $120.23 / $158.49
| Professional | TC | $75.86 | $120.23 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $112.20 / $173.78
| Professional | | $25.12 | $112.20 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $97.72 / $173.78
| Professional | | $81.28 | $97.72 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $19.50 / $31.62
| Professional | 26 | $17.38 | $19.50 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $79.43 / $138.04
| Professional | TC | $66.07 | $79.43 | $138.04 |