- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | 26 | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $104.71 / $275.42
| Professional | | $72.44 | $104.71 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $12.88 / $54.95
| Professional | 26 | $10.96 | $12.88 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $89.13 / $218.78
| Professional | TC | $63.10 | $89.13 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $194.98
| Professional | | $91.20 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $15.85 / $25.70
| Professional | 26 | $11.48 | $15.85 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $114.82 / $169.82
| Professional | TC | $81.28 | $114.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $288.40
| Professional | | $112.20 | $151.36 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $15.49 / $25.12
| Professional | 26 | $11.22 | $15.49 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $245.47
| Professional | TC | $100.00 | $131.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $23.44
| Professional | 26 | $23.44 | $23.44 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $251.19
| Professional | | $107.15 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $14.13 / $24.55
| Professional | 26 | $11.48 | $14.13 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $134.90 / $229.09
| Professional | TC | $95.50 | $134.90 | $229.09 |