- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Facility | 26 | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $281.84 / $524.81
| Professional | | $173.78 | $281.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $44.67 / $75.86
| Professional | 26 | $25.70 | $44.67 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $245.47 / $446.68
| Professional | TC | $131.83 | $245.47 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Professional | 26 | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Professional | TC | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $323.59 / $416.87
| Professional | | $223.87 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $50.12 / $61.66
| Professional | 26 | $48.98 | $50.12 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $354.81
| Professional | TC | $173.78 | $269.15 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.90 / $38.90
| Professional | 26 | $38.02 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $131.83 / $512.86
| Professional | | $93.33 | $131.83 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $24.55 / $70.79
| Professional | 26 | $19.05 | $24.55 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $100.00 / $436.52
| Professional | TC | $70.79 | $100.00 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $275.42 / $575.44
| Professional | | $123.03 | $275.42 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $46.77 / $81.28
| Professional | 26 | $26.92 | $46.77 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $263.03 / $501.19
| Professional | TC | $95.50 | $263.03 | $501.19 |