- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | 26 | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $74.13 / $239.88
| Professional | | $53.70 | $74.13 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $19.95 / $93.33
| Professional | 26 | $15.85 | $19.95 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $45.71 / $81.28
| Professional | TC | $37.15 | $45.71 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $117.49
| Professional | | $91.20 | $112.20 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $35.48 / $37.15
| Professional | 26 | $27.54 | $35.48 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $77.62 / $81.28
| Professional | TC | $61.66 | $77.62 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $102.33 / $123.03
| Professional | | $70.79 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $29.51 / $36.31
| Professional | 26 | $21.38 | $29.51 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $70.79 / $87.10
| Professional | TC | $47.86 | $70.79 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | 26 | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $112.20 / $144.54
| Professional | | $61.66 | $112.20 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $32.36 / $42.66
| Professional | 26 | $18.20 | $32.36 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $77.62 / $100.00
| Professional | TC | $42.66 | $77.62 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $91.20 / $147.91
| Professional | | $77.62 | $91.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $26.92 / $40.74
| Professional | 26 | $22.91 | $26.92 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $104.71
| Professional | TC | $54.95 | $64.57 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $107.15
| Professional | | $60.26 | $60.26 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $17.78 / $33.11
| Professional | 26 | $17.78 | $17.78 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $72.44
| Professional | TC | $42.66 | $42.66 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $123.03
| Professional | | $64.57 | $87.10 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $26.30 / $38.02
| Professional | 26 | $19.05 | $26.30 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $58.88 / $87.10
| Professional | TC | $44.67 | $58.88 | $87.10 |