- 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
- $131.83 / $181.97 / $446.68
| Professional | | $131.83 | $181.97 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $64.57 / $134.90
| Professional | 26 | $42.66 | $64.57 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | 52 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $316.23
| Professional | TC | $93.33 | $123.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $141.25 / $239.88
| Professional | | $120.23 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $54.95 / $60.26
| Professional | 26 | $34.67 | $54.95 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $204.17
| Professional | | $109.65 | $158.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $48.98 / $63.10
| Professional | 26 | $34.67 | $48.98 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $109.65 / $138.04
| Professional | TC | $75.86 | $109.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $190.55 / $346.74
| Professional | | $112.20 | $190.55 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $117.49
| Professional | 26 | $39.81 | $61.66 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $138.04 / $269.15
| Professional | TC | $91.20 | $138.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $269.15
| Professional | | $123.03 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $53.70 / $95.50
| Professional | 26 | $38.02 | $53.70 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $120.23 / $186.21
| Professional | TC | $91.20 | $120.23 | $186.21 |