- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Facility | 26 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $302.00 / $575.44
| Facility | TC | $81.28 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $48.98 / $131.83
| Professional | | $32.36 | $48.98 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $15.85 / $51.29
| Professional | 26 | $10.00 | $15.85 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $33.11 / $93.33
| Professional | TC | $20.89 | $33.11 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $134.90
| Professional | | $57.54 | $70.79 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $25.70 / $50.12
| Professional | 26 | $16.98 | $25.70 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $44.67 / $87.10
| Professional | TC | $38.90 | $44.67 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Facility | 26 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $302.00
| Facility | TC | $81.28 | $81.28 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $112.20 / $181.97
| Professional | | $52.48 | $112.20 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $38.90 / $83.18
| Professional | 26 | $15.85 | $38.90 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $81.28 / $158.49
| Professional | TC | $33.11 | $81.28 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $288.40
| Professional | | $173.78 | $181.97 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $63.10 / $100.00
| Professional | 26 | $48.98 | $63.10 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $181.97
| Professional | TC | $102.33 | $125.89 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $112.20 / $134.90
| Professional | | $60.26 | $112.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $23.99 / $52.48
| Professional | 26 | $11.22 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $40.74 / $87.10
| Professional | TC | $28.18 | $40.74 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $107.15 / $229.09
| Professional | | $52.48 | $107.15 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $40.74 / $87.10
| Professional | 26 | $15.85 | $40.74 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $66.07 / $131.83
| Professional | TC | $37.15 | $66.07 | $131.83 |