- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $295.12 / $295.12
| Facility | 26 | $43.65 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $177.83 / $630.96
| Professional | | $64.57 | $177.83 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $43.65 / $102.33
| Professional | 26 | $28.84 | $43.65 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $97.72 / $537.03
| Professional | TC | $75.86 | $97.72 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $263.03
| Professional | | $131.83 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $52.48 / $81.28
| Professional | 26 | $40.74 | $52.48 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $177.83
| Professional | TC | $91.20 | $117.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $194.98
| Professional | | $32.36 | $33.11 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $208.93 / $263.03
| Professional | | $173.78 | $208.93 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $63.10 / $81.28
| Professional | 26 | $53.70 | $63.10 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $144.54 / $181.97
| Professional | TC | $123.03 | $144.54 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $194.98 / $281.84
| Professional | | $117.49 | $194.98 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $60.26 / $91.20
| Professional | 26 | $37.15 | $60.26 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $131.83 / $169.82
| Professional | TC | $81.28 | $131.83 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $134.90 / $218.78
| Professional | | $54.95 | $134.90 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $223.87
| Professional | | $112.20 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $45.71 / $69.18
| Professional | 26 | $39.81 | $45.71 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $154.88
| Professional | TC | $89.13 | $104.71 | $154.88 |