- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $91.20 / $229.09
| Facility | 26 | $30.90 | $91.20 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $144.54 / $331.13
| Professional | | $93.33 | $144.54 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $38.90 / $97.72
| Professional | 26 | $28.18 | $38.90 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $199.53
| Professional | TC | $93.33 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $295.12
| Professional | | $114.82 | $151.36 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $36.31 / $38.02
| Professional | 26 | $33.88 | $36.31 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $134.90
| Professional | TC | $114.82 | $128.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $177.83 / $354.81
| Professional | | $120.23 | $177.83 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $40.74 / $81.28
| Professional | 26 | $28.18 | $40.74 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $128.82 / $275.42
| Professional | TC | $89.13 | $128.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $346.74
| Professional | | $141.25 | $165.96 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $38.02 / $77.62
| Professional | 26 | $32.36 | $38.02 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $128.82 / $269.15
| Professional | TC | $109.65 | $128.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $186.21 / $501.19
| Professional | | $125.89 | $186.21 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $63.10 / $223.87
| Professional | 26 | $33.11 | $63.10 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $144.54 / $389.05
| Professional | TC | $95.50 | $144.54 | $389.05 |