- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | 26 | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $177.83 / $407.38
| Professional | | $147.91 | $177.83 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $60.26
| Professional | 26 | $21.88 | $25.70 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $151.36 / $309.03
| Professional | TC | $123.03 | $151.36 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $199.53 / $371.54
| Professional | | $147.91 | $199.53 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $29.51 / $52.48
| Professional | 26 | $21.88 | $29.51 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $169.82 / $316.23
| Professional | TC | $125.89 | $169.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $245.47 / $380.19
| Professional | | $177.83 | $245.47 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $33.88 / $56.23
| Professional | 26 | $25.70 | $33.88 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $213.80 / $323.59
| Professional | TC | $131.83 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $269.15 / $467.74
| Professional | | $194.98 | $269.15 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $67.61
| Professional | 26 | $28.18 | $37.15 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $223.87 / $407.38
| Professional | TC | $165.96 | $223.87 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $407.38
| Professional | | $151.36 | $204.17 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.84 / $53.70
| Professional | 26 | $21.88 | $28.84 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $177.83 / $354.81
| Professional | TC | $125.89 | $177.83 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $251.19 / $467.74
| Professional | | $165.96 | $251.19 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $36.31 / $75.86
| Professional | 26 | $24.55 | $36.31 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $213.80 / $354.81
| Professional | TC | $141.25 | $213.80 | $354.81 |