- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | 26 | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $245.47 / $389.05
| Professional | | $173.78 | $245.47 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $38.90 / $104.71
| Professional | 26 | $28.84 | $38.90 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $446.68
| Professional | TC | $134.90 | $208.93 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $173.78
| Professional | | $128.82 | $128.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $44.67
| Professional | 26 | $19.50 | $19.50 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $234.42 / $275.42
| Professional | | $173.78 | $234.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $208.93 / $467.74
| Professional | | $104.71 | $208.93 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $35.48 / $70.79
| Professional | 26 | $21.38 | $35.48 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $169.82 / $407.38
| Professional | TC | $83.18 | $169.82 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $229.09 / $346.74
| Professional | | $147.91 | $229.09 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $46.77 / $75.86
| Professional | 26 | $31.62 | $46.77 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $302.00
| Professional | TC | $114.82 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $316.23
| Professional | | $32.36 | $33.11 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $199.53 / $630.96
| Professional | | $123.03 | $199.53 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $28.18 / $93.33
| Professional | 26 | $20.89 | $28.18 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $173.78 / $549.54
| Professional | TC | $95.50 | $173.78 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $208.93 / $269.15
| Professional | | $93.33 | $208.93 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $30.90 / $39.81
| Professional | 26 | $13.80 | $30.90 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $177.83 / $229.09
| Professional | TC | $79.43 | $177.83 | $229.09 |