- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $15.85
| Facility | 26 | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $58.88 / $288.40
| Professional | | $43.65 | $58.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.85 / $81.28
| Professional | 26 | $12.02 | $15.85 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $41.69 / $112.20
| Professional | TC | $30.90 | $41.69 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $72.44 / $109.65
| Professional | | $53.70 | $72.44 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $20.42 / $30.90
| Professional | 26 | $15.49 | $20.42 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $51.29 / $79.43
| Professional | TC | $37.15 | $51.29 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $89.13
| Professional | | $32.36 | $33.11 | $89.13 |
- 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
- $72.44 / $89.13 / $114.82
| Professional | | $72.44 | $89.13 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $23.44 / $32.36
| Professional | 26 | $19.50 | $23.44 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $81.28
| Professional | TC | $52.48 | $64.57 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $83.18 / $112.20
| Professional | | $51.29 | $83.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.39 / $33.88
| Professional | 26 | $14.13 | $22.39 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $60.26 / $79.43
| Professional | TC | $38.02 | $60.26 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $57.54 / $95.50
| Professional | | $19.95 | $57.54 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $44.67 / $93.33
| Professional | | $39.81 | $44.67 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $12.02 / $25.12
| Professional | 26 | $10.72 | $12.02 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $31.62 / $67.61
| Professional | TC | $28.18 | $31.62 | $67.61 |