- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Facility | 26 | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $47.86 / $100.00
| Professional | | $38.90 | $47.86 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.24 / $16.60 / $38.02
| Professional | 26 | $3.24 | $16.60 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $30.20 / $58.88
| Professional | TC | $24.55 | $30.20 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $97.72
| Professional | | $41.69 | $58.88 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $21.88 / $34.67
| Professional | 26 | $14.79 | $21.88 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $36.31 / $54.95
| Professional | TC | $23.99 | $36.31 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $32.36 / $37.15
| Professional | | $28.18 | $32.36 | $37.15 |
- 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
- $66.07 / $77.62 / $87.10
| Professional | | $66.07 | $77.62 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $26.92 / $36.31
| Professional | 26 | $22.91 | $26.92 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $45.71 / $56.23
| Professional | TC | $39.81 | $45.71 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $70.79 / $93.33
| Professional | | $44.67 | $70.79 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $25.70 / $38.02
| Professional | 26 | $15.85 | $25.70 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $45.71 / $51.29
| Professional | TC | $29.51 | $45.71 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $44.67 / $83.18
| Professional | | $23.44 | $44.67 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $46.77 / $77.62
| Professional | | $39.81 | $46.77 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $17.78 / $29.51
| Professional | 26 | $14.79 | $17.78 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $28.84 / $47.86
| Professional | TC | $23.44 | $28.84 | $47.86 |