- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $112.20
| Facility | 26 | $25.12 | $25.12 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $208.93
| Professional | | $54.95 | $69.18 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $20.89 / $79.43
| Professional | 26 | $15.85 | $20.89 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $46.77 / $91.20
| Professional | TC | $38.02 | $46.77 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $66.07 / $125.89
| Professional | | $54.95 | $66.07 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $19.95 / $38.02
| Professional | 26 | $16.98 | $19.95 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $46.77 / $87.10
| Professional | TC | $38.02 | $46.77 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $138.04
| Professional | | $64.57 | $91.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $27.54 / $41.69
| Professional | 26 | $20.42 | $27.54 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $64.57 / $97.72
| Professional | TC | $44.67 | $64.57 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $95.50 / $186.21
| Professional | | $67.61 | $95.50 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $26.92 / $52.48
| Professional | 26 | $19.50 | $26.92 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $67.61 / $131.83
| Professional | TC | $48.98 | $67.61 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | 26 | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $141.25
| Professional | | $57.54 | $70.79 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $20.89 / $41.69
| Professional | 26 | $16.98 | $20.89 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $50.12 / $102.33
| Professional | TC | $38.90 | $50.12 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $89.13 / $141.25
| Professional | | $63.10 | $89.13 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $26.92 / $41.69
| Professional | 26 | $19.05 | $26.92 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $61.66 / $102.33
| Professional | TC | $44.67 | $61.66 | $102.33 |