- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $38.90
| Facility | 26 | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $371.54
| Professional | | $114.82 | $165.96 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $57.54 / $123.03
| Professional | 26 | $41.69 | $57.54 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $239.88
| Professional | TC | $67.61 | $102.33 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $190.55
| Professional | | $114.82 | $165.96 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $52.48 / $60.26
| Professional | 26 | $48.98 | $52.48 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $131.83
| Professional | TC | $107.15 | $114.82 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Facility | 26 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $323.59
| Professional | | $114.82 | $194.98 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $51.29 / $97.72
| Professional | 26 | $34.67 | $51.29 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $141.25 / $245.47
| Professional | TC | $75.86 | $141.25 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $158.49 / $208.93
| Professional | | $138.04 | $158.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $51.29 / $69.18
| Professional | 26 | $44.67 | $51.29 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $144.54
| Professional | TC | $93.33 | $109.65 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $173.78 / $302.00
| Professional | | $109.65 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $52.48 / $100.00
| Professional | 26 | $32.36 | $52.48 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $213.80
| Professional | TC | $77.62 | $117.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $213.80
| Professional | | $107.15 | $151.36 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $48.98 / $69.18
| Professional | 26 | $35.48 | $48.98 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $102.33 / $144.54
| Professional | TC | $70.79 | $102.33 | $144.54 |