- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Facility | 26 | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $125.89 / $316.23
| Professional | | $56.23 | $125.89 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $28.84 / $75.86
| Professional | 26 | $15.85 | $28.84 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $107.15 / $223.87
| Professional | TC | $93.33 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $263.03
| Professional | | $138.04 | $190.55 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $30.20 / $48.98
| Professional | 26 | $19.95 | $30.20 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $213.80
| Professional | TC | $114.82 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $138.04
| Professional | | $32.36 | $33.11 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $239.88
| Professional | | $141.25 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $29.51 / $40.74
| Professional | 26 | $21.38 | $29.51 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $194.98
| Professional | TC | $114.82 | $147.91 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $218.78 / $316.23
| Professional | | $114.82 | $218.78 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $41.69 / $63.10
| Professional | 26 | $22.39 | $41.69 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $173.78 / $213.80
| Professional | TC | $93.33 | $173.78 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $131.83 / $199.53
| Professional | | $30.20 | $131.83 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $154.88 / $263.03
| Professional | | $112.20 | $154.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $25.12 / $41.69
| Professional | 26 | $18.20 | $25.12 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $223.87
| Professional | TC | $91.20 | $128.82 | $223.87 |