- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | 26 | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $346.74
| Professional | | $87.10 | $109.65 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $97.72 / $269.15
| Professional | 26 | $67.61 | $97.72 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $25.12 / $87.10
| Professional | TC | $20.89 | $25.12 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $40.74
| Professional | 26 | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $128.82 / $186.21
| Professional | | $93.33 | $128.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $75.86 / $204.17
| Professional | | $53.70 | $75.86 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $44.67 / $144.54
| Professional | 26 | $39.81 | $44.67 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $13.49 / $29.51 / $69.18
| Professional | TC | $13.49 | $29.51 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $416.87
| Professional | | $128.82 | $194.98 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $144.54 / $467.74
| Professional | 26 | $97.72 | $144.54 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $54.95 / $467.74
| Professional | TC | $33.11 | $54.95 | $467.74 |
- 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
- $72.44 / $128.82 / $204.17
| Professional | | $72.44 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $93.33 / $229.09
| Professional | 26 | $56.23 | $93.33 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $30.20 / $63.10
| Professional | TC | $16.98 | $30.20 | $63.10 |