- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $25.70
| Facility | 26 | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $245.47
| Professional | | $81.28 | $104.71 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $30.90 / $70.79
| Professional | 26 | $22.91 | $30.90 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $158.49
| Professional | TC | $58.88 | $77.62 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $22.39 / $22.39
| Facility | 26 | $18.62 | $22.39 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $245.47 / $354.81
| Professional | | $162.18 | $245.47 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $64.57 / $93.33
| Professional | 26 | $42.66 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $194.98 / $263.03
| Professional | TC | $123.03 | $194.98 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $95.50 / $229.09
| Facility | 26 | $40.74 | $95.50 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $194.98 / $316.23
| Professional | | $104.71 | $194.98 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $50.12 / $81.28
| Professional | 26 | $28.84 | $50.12 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $141.25 / $229.09
| Professional | TC | $74.13 | $141.25 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $93.33 / $181.97
| Facility | 26 | $74.13 | $93.33 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $251.19
| Professional | | $151.36 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $64.57
| Professional | 26 | $38.90 | $38.90 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $186.21
| Professional | TC | $112.20 | $112.20 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $645.65
| Professional | | $91.20 | $151.36 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $48.98 / $165.96
| Professional | 26 | $26.92 | $48.98 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $109.65 / $478.63
| Professional | TC | $64.57 | $109.65 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $309.03
| Professional | | $95.50 | $151.36 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $87.10 / $213.80
| Professional | 26 | $30.90 | $87.10 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $109.65 / $229.09
| Professional | TC | $66.07 | $109.65 | $229.09 |