- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $15.85
| Facility | 26 | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $120.23 / $151.36
| Professional | | $95.50 | $120.23 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $14.13 / $18.20
| Professional | 26 | $11.48 | $14.13 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $131.83
| Professional | TC | $83.18 | $104.71 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $13.18 / $13.18
| Facility | 26 | $13.18 | $13.18 | $13.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $354.81 / $478.63
| Professional | | $190.55 | $354.81 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $38.90 / $52.48
| Professional | 26 | $21.38 | $38.90 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $316.23 / $426.58
| Professional | TC | $169.82 | $316.23 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $46.77 / $53.70
| Facility | 26 | $33.88 | $46.77 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $316.23 / $524.81
| Professional | | $123.03 | $316.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $33.88 / $56.23
| Professional | 26 | $14.45 | $33.88 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $281.84 / $467.74
| Professional | TC | $109.65 | $281.84 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $42.66 / $87.10
| Facility | 26 | $33.88 | $42.66 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $316.23 / $457.09
| Professional | | $199.53 | $316.23 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $33.88 / $48.98
| Professional | 26 | $21.38 | $33.88 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $281.84 / $407.38
| Professional | TC | $169.82 | $281.84 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $186.21 / $446.68
| Professional | | $97.72 | $186.21 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $22.91 / $61.66
| Professional | 26 | $13.49 | $22.91 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $141.25 / $398.11
| Professional | TC | $81.28 | $141.25 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $389.05
| Professional | | $95.50 | $169.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $22.91 / $44.67
| Professional | 26 | $13.49 | $22.91 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $151.36 / $331.13
| Professional | TC | $83.18 | $151.36 | $331.13 |