- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | 26 | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $181.97
| Professional | | $57.54 | $77.62 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $61.66 / $229.09
| Professional | 26 | $40.74 | $61.66 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $25.70 / $61.66
| Professional | TC | $16.98 | $25.70 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $35.48 / $93.33
| Professional | 26 | $14.13 | $35.48 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $33.88 / $91.20
| Professional | | $25.12 | $33.88 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $74.13 / $144.54
| Professional | | $44.67 | $74.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $51.29 / $100.00
| Professional | 26 | $30.20 | $51.29 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $22.91 / $45.71
| Professional | TC | $14.13 | $22.91 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $169.82
| Professional | | $67.61 | $93.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $66.07 / $112.20
| Professional | 26 | $43.65 | $66.07 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $28.84 / $57.54
| Professional | TC | $21.88 | $28.84 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $93.33
| Professional | | $32.36 | $33.11 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $57.54 / $199.53
| Professional | | $41.69 | $57.54 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $39.81 / $131.83
| Professional | 26 | $29.51 | $39.81 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $18.62 / $53.70
| Professional | TC | $12.88 | $18.62 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $69.18 / $89.13
| Professional | | $31.62 | $69.18 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $45.71 / $57.54
| Professional | 26 | $20.42 | $45.71 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.72 / $23.99 / $31.62
| Professional | TC | $10.72 | $23.99 | $31.62 |