- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | 26 | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $162.18 / $346.74
| Professional | | $89.13 | $162.18 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $131.83 / $275.42
| Professional | 26 | $87.10 | $131.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $36.31 / $104.71
| Professional | TC | $16.98 | $36.31 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $158.49
| Professional | | $107.15 | $114.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $87.10 / $138.04
| Professional | 26 | $83.18 | $87.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $263.03 / $309.03
| Professional | | $181.97 | $263.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $204.17 / $239.88
| Professional | 26 | $144.54 | $204.17 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $57.54 / $67.61
| Professional | TC | $40.74 | $57.54 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $489.78
| Professional | | $131.83 | $208.93 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $218.78
| Professional | 26 | $104.71 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $52.48 / $281.84
| Professional | TC | $33.11 | $52.48 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $446.68
| Professional | | $104.71 | $158.49 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $165.96
| Professional | 26 | $81.28 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $32.36 / $316.23
| Professional | TC | $19.95 | $32.36 | $316.23 |