- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $181.97 / $436.52
| Professional | | $89.13 | $181.97 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $72.44 / $151.36
| Professional | 26 | $34.67 | $72.44 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $204.17
| Professional | TC | $54.95 | $83.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $144.54 / $144.54
| Professional | | $56.23 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $69.18
| Facility | 26 | $56.23 | $56.23 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $218.78
| Professional | | $95.50 | $138.04 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $54.95 / $83.18
| Professional | 26 | $36.31 | $54.95 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $87.10 / $134.90
| Professional | TC | $57.54 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $162.18 / $204.17
| Professional | | $158.49 | $162.18 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $69.18
| Facility | 26 | $56.23 | $56.23 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $162.18 / $218.78
| Professional | | $114.82 | $162.18 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $74.13
| Professional | 26 | $37.15 | $56.23 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $91.20 / $128.82
| Professional | TC | $60.26 | $91.20 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $102.33 / $186.21
| Professional | | $97.72 | $102.33 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.90 / $87.10
| Professional | 26 | $38.02 | $38.90 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $67.61 / $128.82
| Professional | TC | $58.88 | $67.61 | $128.82 |