- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | 26 | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $69.18 / $131.83
| Professional | | $53.70 | $69.18 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $22.91 / $54.95
| Professional | 26 | $16.98 | $22.91 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $46.77 / $87.10
| Professional | TC | $37.15 | $46.77 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $134.90
| Professional | | $60.26 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $30.20 / $45.71
| Professional | 26 | $20.89 | $30.20 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $53.70 / $85.11
| Professional | TC | $41.69 | $53.70 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $67.61
| Professional | | $32.36 | $33.11 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $141.25
| Professional | | $91.20 | $107.15 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $33.88 / $48.98
| Professional | 26 | $28.84 | $33.88 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $74.13 / $93.33
| Professional | TC | $61.66 | $74.13 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $100.00 / $134.90
| Professional | | $61.66 | $100.00 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $33.11 / $48.98
| Professional | 26 | $20.42 | $33.11 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $67.61 / $85.11
| Professional | TC | $41.69 | $67.61 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $64.57 / $114.82
| Professional | | $29.51 | $64.57 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $67.61 / $114.82
| Professional | | $57.54 | $67.61 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $22.91 / $38.02
| Professional | 26 | $19.50 | $22.91 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $45.71 / $79.43
| Professional | TC | $38.90 | $45.71 | $79.43 |