- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Facility | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $67.61 / $158.49
| Professional | | $46.77 | $67.61 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $23.99 / $72.44
| Professional | 26 | $15.85 | $23.99 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $41.69 / $89.13
| Professional | TC | $30.20 | $41.69 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $104.71 / $165.96
| Professional | | $56.23 | $104.71 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $30.20 / $60.26
| Professional | 26 | $18.20 | $30.20 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $67.61 / $104.71
| Professional | TC | $38.02 | $67.61 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Facility | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $138.04 / $223.87
| Professional | | $64.57 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $51.29 / $89.13
| Professional | 26 | $20.42 | $51.29 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $91.20 / $134.90
| Professional | TC | $46.77 | $91.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $281.84
| Professional | | $204.17 | $204.17 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $95.50
| Professional | 26 | $57.54 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $134.90 / $177.83
| Professional | TC | $112.20 | $134.90 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $100.00 / $158.49
| Professional | | $53.70 | $100.00 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $25.12 / $64.57
| Professional | 26 | $17.38 | $25.12 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $48.98 / $104.71
| Professional | TC | $32.36 | $48.98 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $131.83 / $165.96
| Professional | | $85.11 | $131.83 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $52.48 / $77.62
| Professional | 26 | $26.92 | $52.48 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $114.82
| Professional | TC | $57.54 | $79.43 | $114.82 |