- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | 26 | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $75.86 / $165.96
| Professional | | $47.86 | $75.86 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $38.90 / $151.36
| Professional | 26 | $22.91 | $38.90 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $39.81 / $83.18
| Professional | TC | $25.12 | $39.81 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $46.77 / $109.65
| Professional | 26 | $26.30 | $46.77 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $134.90
| Professional | | $67.61 | $93.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $45.71 / $66.07
| Professional | 26 | $32.36 | $45.71 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $47.86 / $69.18
| Professional | TC | $34.67 | $47.86 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $107.15 / $199.53
| Professional | | $83.18 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $45.71 / $97.72
| Professional | 26 | $38.90 | $45.71 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $67.61 / $104.71
| Professional | TC | $44.67 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $128.82 / $208.93
| Professional | | $74.13 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $64.57 / $97.72
| Professional | 26 | $38.02 | $64.57 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $67.61 / $107.15
| Professional | TC | $39.81 | $67.61 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $95.50 / $245.47
| Professional | | $74.13 | $95.50 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $43.65 / $100.00
| Professional | 26 | $33.88 | $43.65 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $51.29 / $107.15
| Professional | TC | $39.81 | $51.29 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $24.55 / $24.55
| Facility | 26 | $24.55 | $24.55 | $24.55 |