- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Facility | 26 | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $173.78 / $363.08
| Professional | | $91.20 | $173.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $20.89 / $79.43
| Professional | 26 | $15.85 | $20.89 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $204.17
| Professional | TC | $109.65 | $154.88 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $501.19 / $707.95
| Professional | | $316.23 | $501.19 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $57.54 / $83.18
| Professional | 26 | $37.15 | $57.54 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $467.74 / $630.96
| Professional | TC | $281.84 | $467.74 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $169.82 / $199.53
| Facility | 26 | $37.15 | $169.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $331.13 / $416.87
| Professional | | $263.03 | $331.13 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $37.15 / $47.86
| Professional | 26 | $29.51 | $37.15 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $288.40 / $371.54
| Professional | TC | $229.09 | $288.40 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $158.49 / $158.49
| Facility | 26 | $29.51 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $257.04 / $380.19
| Professional | | $239.88 | $257.04 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $29.51 / $53.70
| Professional | 26 | $29.51 | $29.51 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $229.09 / $338.84
| Professional | TC | $204.17 | $229.09 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | 26 | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $218.78 / $1,348.96
| Professional | | $109.65 | $218.78 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $64.57 / $162.18
| Professional | 26 | $20.89 | $64.57 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $181.97 / $1,202.26
| Professional | TC | $93.33 | $181.97 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $363.08 / $660.69
| Professional | | $109.65 | $363.08 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $57.54 / $95.50
| Professional | 26 | $25.70 | $57.54 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $316.23 / $588.84
| Professional | TC | $93.33 | $316.23 | $588.84 |