- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $63.10 / $63.10
| Facility | 26 | $43.65 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $190.55 / $331.13
| Professional | | $100.00 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $77.62 / $151.36
| Professional | 26 | $39.81 | $77.62 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $165.96
| Professional | TC | $57.54 | $79.43 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $89.13 / $144.54
| Professional | | $75.86 | $89.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $50.12 / $67.61
| Professional | 26 | $34.67 | $50.12 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $57.54 / $67.61
| Professional | TC | $52.48 | $57.54 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $114.82 / $128.82
| Professional | | $81.28 | $114.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $48.98 / $54.95
| Professional | 26 | $33.88 | $48.98 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $67.61 / $74.13
| Professional | TC | $46.77 | $67.61 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | 26 | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $144.54 / $316.23
| Professional | | $91.20 | $144.54 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $128.82
| Professional | 26 | $39.81 | $61.66 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $89.13 / $194.98
| Professional | TC | $57.54 | $89.13 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $199.53
| Professional | | $91.20 | $114.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $48.98 / $95.50
| Professional | 26 | $38.02 | $48.98 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $120.23
| Professional | TC | $54.95 | $69.18 | $120.23 |