- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $46.77 / $199.53
| Professional | | $30.90 | $46.77 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $43.65 / $83.18
| Professional | 26 | $22.91 | $43.65 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $22.91 / $117.49
| Professional | TC | $12.88 | $22.91 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $218.78
| Professional | | $147.91 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $85.11
| Professional | 26 | $83.18 | $83.18 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $131.83
| Professional | TC | $66.07 | $66.07 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $147.91 / $147.91
| Facility | 26 | $75.86 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $104.71 / $147.91
| Professional | | $45.71 | $104.71 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $61.66 / $87.10
| Professional | 26 | $25.12 | $61.66 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $46.77 / $95.50
| Professional | TC | $19.05 | $46.77 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $457.09
| Professional | | $158.49 | $158.49 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $95.50 / $208.93
| Professional | 26 | $89.13 | $95.50 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $245.47
| Professional | TC | $63.10 | $63.10 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $109.65 / $218.78
| Professional | | $48.98 | $109.65 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $32.36 / $85.11
| Professional | 26 | $22.39 | $32.36 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $131.83
| Professional | TC | $26.92 | $38.90 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $190.55 / $691.83
| Professional | | $112.20 | $190.55 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $100.00 / $380.19
| Professional | 26 | $36.31 | $100.00 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $123.03 / $302.00
| Professional | TC | $52.48 | $123.03 | $302.00 |