- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | 26 | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $74.13 / $125.89
| Professional | | $64.57 | $74.13 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $41.69 / $87.10
| Professional | 26 | $28.84 | $41.69 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $33.88 / $52.48
| Professional | TC | $22.39 | $33.88 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $147.91
| Professional | | $67.61 | $93.33 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $61.66 / $95.50
| Professional | 26 | $36.31 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $38.02 / $60.26
| Professional | TC | $25.12 | $38.02 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $120.23
| Professional | | $32.36 | $33.11 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $251.19
| Professional | | $107.15 | $138.04 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $74.13 / $251.19
| Professional | 26 | $56.23 | $74.13 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $53.70 / $77.62
| Professional | TC | $37.15 | $53.70 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $109.65 / $131.83
| Professional | | $67.61 | $109.65 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $56.23 / $89.13
| Professional | 26 | $34.67 | $56.23 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $47.86 / $56.23
| Professional | TC | $33.88 | $47.86 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $56.23 / $117.49
| Professional | | $33.88 | $56.23 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $112.20
| Professional | | $58.88 | $75.86 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $44.67 / $64.57
| Professional | 26 | $32.36 | $44.67 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $28.84 / $47.86
| Professional | TC | $20.89 | $28.84 | $47.86 |