- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $70.79 / $245.47
| Professional | | $34.67 | $70.79 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $44.67 / $131.83
| Professional | 26 | $22.91 | $44.67 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $43.65 / $102.33
| Professional | TC | $14.13 | $43.65 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $95.50 / $112.20
| Professional | | $47.86 | $95.50 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $36.31 / $45.71
| Professional | 26 | $28.18 | $36.31 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $60.26 / $74.13
| Professional | TC | $19.05 | $60.26 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $151.36
| Professional | | $32.36 | $33.11 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | 26 | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $67.61 / $162.18
| Professional | | $58.88 | $67.61 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $40.74 / $58.88
| Professional | 26 | $35.48 | $40.74 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $26.92 / $102.33
| Professional | TC | $23.44 | $26.92 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $74.13 / $144.54
| Professional | | $38.02 | $74.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $43.65 / $57.54
| Professional | 26 | $23.44 | $43.65 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $29.51 / $91.20
| Professional | TC | $16.98 | $29.51 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $38.02 / $72.44
| Professional | | $22.91 | $38.02 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $89.13 / $245.47
| Professional | | $47.86 | $89.13 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $33.11 / $95.50
| Professional | 26 | $28.18 | $33.11 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $56.23 / $83.18
| Professional | TC | $23.99 | $56.23 | $83.18 |