- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Facility | 26 | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $173.78
| Professional | | $50.12 | $64.57 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $20.89 / $58.88
| Professional | 26 | $18.20 | $20.89 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $44.67 / $114.82
| Professional | TC | $30.90 | $44.67 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $213.80 / $309.03
| Professional | | $138.04 | $213.80 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $63.10 / $91.20
| Professional | 26 | $40.74 | $63.10 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $158.49 / $213.80
| Professional | TC | $95.50 | $158.49 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $186.21 / $223.87
| Facility | 26 | $38.90 | $186.21 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $131.83 / $186.21
| Professional | | $104.71 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $38.90 / $54.95
| Professional | 26 | $31.62 | $38.90 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $93.33 / $131.83
| Professional | TC | $74.13 | $93.33 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $177.83 / $177.83
| Facility | 26 | $30.90 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $398.11
| Professional | | $104.71 | $104.71 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $181.97
| Professional | 26 | $30.90 | $30.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $199.53
| Professional | TC | $74.13 | $74.13 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $131.83 / $457.09
| Professional | | $43.65 | $131.83 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $48.98 / $158.49
| Professional | 26 | $16.22 | $48.98 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $85.11 / $302.00
| Professional | TC | $27.54 | $85.11 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $151.36 / $281.84
| Professional | | $58.88 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $60.26 / $131.83
| Professional | 26 | $26.92 | $60.26 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $95.50 / $194.98
| Professional | TC | $37.15 | $95.50 | $194.98 |