- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Facility | 26 | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $93.33 / $173.78
| Professional | | $70.79 | $93.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $64.57 / $114.82
| Professional | TC | $47.86 | $64.57 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $23.44 / $23.44
| Facility | 26 | $19.50 | $23.44 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $316.23
| Professional | | $144.54 | $218.78 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $162.18 / $218.78
| Professional | TC | $102.33 | $162.18 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $100.00 / $245.47
| Facility | 26 | $42.66 | $100.00 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $281.84
| Professional | | $114.82 | $169.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $120.23 / $194.98
| Professional | TC | $77.62 | $120.23 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $97.72 / $190.55
| Facility | 26 | $77.62 | $97.72 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $223.87
| Professional | | $134.90 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $154.88
| Professional | TC | $93.33 | $93.33 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $169.82 / $676.08
| Professional | | $93.33 | $169.82 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $117.49 / $512.86
| Professional | TC | $64.57 | $117.49 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $158.49 / $288.40
| Professional | | $91.20 | $158.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $114.82 / $199.53
| Professional | TC | $64.57 | $114.82 | $199.53 |