- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $186.21 / $281.84
| Professional | | $138.04 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $93.33 / $141.25
| Professional | 26 | $52.48 | $93.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $95.50 / $213.80
| Professional | TC | $61.66 | $95.50 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $229.09 / $380.19
| Professional | | $162.18 | $229.09 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $173.78
| Professional | 26 | $91.20 | $117.49 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $213.80
| Professional | TC | $72.44 | $100.00 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $363.08 / $645.65
| Professional | | $199.53 | $363.08 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $117.49 / $257.04
| Professional | 26 | $63.10 | $117.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $162.18 / $524.81
| Professional | TC | $70.79 | $162.18 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $245.47 / $467.74
| Professional | | $194.98 | $245.47 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $138.04 / $257.04
| Professional | 26 | $109.65 | $138.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $208.93
| Professional | TC | $87.10 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $223.87 / $389.05
| Professional | | $147.91 | $223.87 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $107.15 / $165.96
| Professional | 26 | $56.23 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $100.00 / $234.42
| Professional | TC | $70.79 | $100.00 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $257.04 / $467.74
| Professional | | $165.96 | $257.04 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $112.20 / $199.53
| Professional | 26 | $85.11 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $138.04 / $251.19
| Professional | TC | $75.86 | $138.04 | $251.19 |