- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | 26 | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $263.03
| Professional | | $107.15 | $154.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $64.57 / $147.91
| Professional | 26 | $42.66 | $64.57 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $77.62 / $162.18
| Professional | TC | $50.12 | $77.62 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | 26 | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $199.53 / $309.03
| Professional | | $125.89 | $199.53 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $104.71 / $138.04
| Professional | 26 | $66.07 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $91.20 / $147.91
| Professional | TC | $58.88 | $91.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $257.04 / $562.34
| Professional | | $147.91 | $257.04 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $95.50 / $177.83
| Professional | 26 | $66.07 | $95.50 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $138.04 / $426.58
| Professional | TC | $70.79 | $138.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $223.87 / $354.81
| Professional | | $144.54 | $223.87 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $117.49 / $173.78
| Professional | 26 | $75.86 | $117.49 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $158.49
| Professional | TC | $69.18 | $107.15 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $251.19 / $575.44
| Professional | | $147.91 | $251.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $93.33 / $177.83
| Professional | 26 | $70.79 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $114.82 / $239.88
| Professional | TC | $70.79 | $114.82 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $53.70 / $64.57
| Facility | 26 | $48.98 | $53.70 | $64.57 |