- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $67.61 / $173.78
| Professional | | $57.54 | $67.61 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $36.31 / $79.43
| Professional | 26 | $25.70 | $36.31 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $34.67 / $72.44
| Professional | TC | $30.20 | $34.67 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $100.00 / $151.36
| Professional | | $67.61 | $100.00 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $42.66 / $64.57
| Professional | 26 | $28.84 | $42.66 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $54.95 / $87.10
| Professional | TC | $38.02 | $54.95 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $177.83
| Professional | | $64.57 | $91.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $38.90 / $61.66
| Professional | 26 | $30.20 | $38.90 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $50.12 / $104.71
| Professional | TC | $34.67 | $50.12 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $107.15 / $199.53
| Professional | | $60.26 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $46.77 / $81.28
| Professional | 26 | $34.67 | $46.77 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $69.18 / $117.49
| Professional | TC | $47.86 | $69.18 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $72.44 / $144.54
| Professional | | $60.26 | $72.44 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $33.11 / $63.10
| Professional | 26 | $26.92 | $33.11 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $38.90 / $83.18
| Professional | TC | $30.90 | $38.90 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $199.53
| Professional | | $60.26 | $87.10 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $39.81 / $74.13
| Professional | 26 | $28.84 | $39.81 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $51.29 / $97.72
| Professional | TC | $30.90 | $51.29 | $97.72 |