- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | 26 | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $288.40
| Professional | | $112.20 | $147.91 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $51.29 / $91.20
| Professional | 26 | $39.81 | $51.29 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $91.20 / $218.78
| Professional | TC | $63.10 | $91.20 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $302.00 / $436.52
| Professional | | $131.83 | $302.00 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $102.33 / $147.91
| Professional | 26 | $44.67 | $102.33 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $199.53 / $295.12
| Professional | TC | $87.10 | $199.53 | $295.12 |
- 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
- $158.49 / $288.40 / $489.78
| Professional | | $158.49 | $288.40 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $75.86 / $134.90
| Professional | 26 | $50.12 | $75.86 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $190.55 / $371.54
| Professional | TC | $112.20 | $190.55 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $239.88 / $354.81
| Professional | | $151.36 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $120.23
| Professional | 26 | $51.29 | $79.43 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $162.18 / $234.42
| Professional | TC | $102.33 | $162.18 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $223.87 / $446.68
| Professional | | $154.88 | $223.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $72.44 / $138.04
| Professional | 26 | $48.98 | $72.44 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $269.15
| Professional | TC | $102.33 | $151.36 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $37.15 / $43.65
| Facility | 26 | $33.88 | $37.15 | $43.65 |