- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Facility | 26 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $275.42
| Professional | | $104.71 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $58.88 / $104.71
| Professional | 26 | $30.20 | $58.88 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $112.20 / $190.55
| Professional | TC | $77.62 | $112.20 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $213.80 / $302.00
| Professional | | $141.25 | $213.80 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $60.26 / $91.20
| Professional | 26 | $34.67 | $60.26 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $204.17
| Professional | TC | $100.00 | $144.54 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $204.17 / $398.11
| Professional | | $125.89 | $204.17 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $61.66 / $128.82
| Professional | 26 | $33.11 | $61.66 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $141.25 / $275.42
| Professional | TC | $93.33 | $141.25 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $223.87 / $426.58
| Professional | | $181.97 | $223.87 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $134.90
| Professional | 26 | $57.54 | $72.44 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $288.40
| Professional | TC | $123.03 | $154.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $354.81
| Professional | | $123.03 | $177.83 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $58.88 / $104.71
| Professional | 26 | $33.11 | $58.88 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $239.88
| Professional | TC | $89.13 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $416.87
| Professional | | $131.83 | $208.93 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $61.66 / $190.55
| Professional | 26 | $46.77 | $61.66 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $147.91 / $263.03
| Professional | TC | $102.33 | $147.91 | $263.03 |