- 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
- $36.31 / $104.71 / $269.15
| Professional | | $36.31 | $104.71 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $60.26 / $107.15
| Professional | 26 | $36.31 | $60.26 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $112.20 / $446.68
| Professional | TC | $85.11 | $112.20 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $229.09
| Professional | | $125.89 | $151.36 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $302.00 / $380.19
| Professional | | $239.88 | $302.00 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $89.13 / $112.20
| Professional | 26 | $70.79 | $89.13 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $263.03
| Professional | TC | $169.82 | $213.80 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $190.55 / $331.13
| Professional | | $120.23 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $72.44 / $97.72
| Professional | 26 | $44.67 | $72.44 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $269.15
| Professional | TC | $95.50 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $269.15 / $295.12
| Professional | | $245.47 | $269.15 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $81.28 / $93.33
| Professional | 26 | $77.62 | $81.28 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $186.21 / $204.17
| Professional | TC | $169.82 | $186.21 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Professional | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | 26 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | TC | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $208.93 / $245.47
| Professional | | $147.91 | $208.93 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $64.57 / $74.13
| Professional | 26 | $46.77 | $64.57 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $169.82
| Professional | TC | $107.15 | $147.91 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $229.09 / $331.13
| Professional | | $134.90 | $229.09 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $66.07 / $97.72
| Professional | 26 | $42.66 | $66.07 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $239.88
| Professional | TC | $104.71 | $162.18 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $275.42 / $275.42
| Professional | | $234.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $83.18 / $83.18
| Professional | 26 | $70.79 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $190.55
| Professional | TC | $162.18 | $190.55 | $190.55 |