- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $97.72 / $257.04
| Professional | | $83.18 | $97.72 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $28.84 / $93.33
| Professional | 26 | $25.12 | $28.84 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $69.18 / $204.17
| Professional | TC | $57.54 | $69.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $13.80 / $13.80
| Professional | 26 | $13.80 | $13.80 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $109.65 / $169.82
| Professional | | $35.48 | $109.65 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $112.20 / $194.98
| Professional | | $48.98 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $33.11 / $58.88
| Professional | 26 | $15.14 | $33.11 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $79.43 / $138.04
| Professional | TC | $33.88 | $79.43 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $194.98 / $691.83
| Professional | | $117.49 | $194.98 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $57.54 / $331.13
| Professional | 26 | $36.31 | $57.54 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $123.03 / $398.11
| Professional | TC | $79.43 | $123.03 | $398.11 |
- 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 / $125.89 / $281.84
| Professional | | $72.44 | $125.89 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $38.90 / $66.07
| Professional | 26 | $21.88 | $38.90 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $87.10 / $208.93
| Professional | TC | $50.12 | $87.10 | $208.93 |