- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Facility | 26 | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $131.83 / $218.78
| Professional | | $74.13 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $48.98 / $83.18
| Professional | 26 | $25.70 | $48.98 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $83.18 / $144.54
| Professional | TC | $47.86 | $83.18 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Professional | 26 | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Professional | TC | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $141.25 / $199.53
| Professional | | $134.90 | $141.25 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $81.28
| Professional | 26 | $51.29 | $51.29 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $91.20 / $123.03
| Professional | TC | $85.11 | $91.20 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Professional | 26 | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $95.50 / $199.53
| Professional | | $51.29 | $95.50 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $28.84 / $77.62
| Professional | 26 | $19.50 | $28.84 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $51.29 / $120.23
| Professional | TC | $31.62 | $51.29 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $131.83 / $234.42
| Professional | | $74.13 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $51.29 / $89.13
| Professional | 26 | $27.54 | $51.29 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $83.18 / $151.36
| Professional | TC | $46.77 | $83.18 | $151.36 |