- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $346.74
| Professional | | $141.25 | $186.21 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $57.54 / $112.20
| Professional | 26 | $46.77 | $57.54 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $239.88
| Professional | TC | $95.50 | $128.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $309.03
| Professional | | $173.78 | $251.19 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $79.43 / $102.33
| Professional | 26 | $53.70 | $79.43 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $208.93
| Professional | TC | $117.49 | $169.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $281.84 / $398.11
| Professional | | $213.80 | $281.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $125.89
| Professional | 26 | $69.18 | $83.18 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $199.53 / $275.42
| Professional | TC | $147.91 | $199.53 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $251.19 / $489.78
| Professional | | $213.80 | $251.19 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $79.43 / $151.36
| Professional | 26 | $67.61 | $79.43 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $169.82 / $331.13
| Professional | TC | $147.91 | $169.82 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $416.87
| Professional | | $151.36 | $204.17 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $141.25
| Professional | 26 | $50.12 | $66.07 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $288.40
| Professional | TC | $100.00 | $138.04 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $257.04 / $489.78
| Professional | | $213.80 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $81.28 / $120.23
| Professional | 26 | $67.61 | $81.28 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $257.04
| Professional | TC | $144.54 | $169.82 | $257.04 |