- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | 26 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $67.61 / $165.96
| Professional | | $47.86 | $67.61 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $47.86 / $117.49
| Professional | 26 | $32.36 | $47.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $19.05 / $48.98
| Professional | TC | $15.14 | $19.05 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $131.83
| Professional | | $64.57 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $64.57 / $93.33
| Professional | 26 | $45.71 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $26.92 / $38.90
| Professional | TC | $19.50 | $26.92 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $91.20 / $194.98
| Professional | | $79.43 | $91.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $138.04
| Professional | 26 | $54.95 | $64.57 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $28.18 / $58.88
| Professional | TC | $24.55 | $28.18 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $131.83 / $213.80
| Professional | | $75.86 | $131.83 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $91.20 / $138.04
| Professional | 26 | $53.70 | $91.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $38.02 / $58.88
| Professional | TC | $22.39 | $38.02 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $89.13 / $234.42
| Professional | | $67.61 | $89.13 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $60.26 / $141.25
| Professional | 26 | $47.86 | $60.26 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $25.12 / $58.88
| Professional | TC | $21.38 | $25.12 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Facility | 26 | $33.88 | $33.88 | $33.88 |