- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 26 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $93.33 / $204.17
| Professional | | $47.86 | $93.33 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $44.67 / $107.15
| Professional | 26 | $25.12 | $44.67 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $54.95 / $95.50
| Professional | TC | $25.12 | $54.95 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $93.33 / $93.33
| Professional | | $42.66 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $52.48
| Facility | 26 | $42.66 | $42.66 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $154.88
| Professional | | $69.18 | $93.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $41.69 / $64.57
| Professional | 26 | $28.18 | $41.69 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $53.70 / $97.72
| Professional | TC | $34.67 | $53.70 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $102.33 / $190.55
| Professional | | $97.72 | $102.33 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $52.48
| Facility | 26 | $42.66 | $42.66 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $100.00 / $154.88
| Professional | | $75.86 | $100.00 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $42.66 / $56.23
| Professional | 26 | $28.84 | $42.66 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $51.29 / $75.86
| Professional | TC | $34.67 | $51.29 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $85.11 / $165.96
| Professional | | $60.26 | $85.11 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $30.20 / $85.11
| Professional | 26 | $29.51 | $30.20 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $42.66 / $83.18
| Professional | TC | $30.20 | $42.66 | $83.18 |