- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Facility | 26 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $213.80
| Professional | | $87.10 | $112.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $77.62 / $100.00
| Professional | 26 | $67.61 | $77.62 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $28.84 / $44.67
| Professional | TC | $19.05 | $28.84 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $154.88 / $208.93
| Professional | | $91.20 | $154.88 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $158.49 / $223.87
| Professional | | $97.72 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $114.82 / $162.18
| Professional | 26 | $70.79 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $44.67 / $61.66
| Professional | TC | $27.54 | $44.67 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $173.78 / $281.84
| Professional | | $79.43 | $173.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $134.90 / $204.17
| Professional | 26 | $61.66 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $45.71 / $79.43
| Professional | TC | $19.50 | $45.71 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $186.21 / $281.84
| Professional | | $93.33 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $134.90 / $223.87
| Professional | 26 | $67.61 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $40.74 / $75.86
| Professional | TC | $20.89 | $40.74 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $229.09 / $269.15
| Professional | | $204.17 | $229.09 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $165.96 / $204.17
| Professional | 26 | $154.88 | $165.96 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $57.54 / $70.79
| Professional | TC | $45.71 | $57.54 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $239.88 / $257.04
| Professional | | $213.80 | $239.88 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $173.78 / $190.55
| Professional | 26 | $154.88 | $173.78 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $64.57 / $69.18
| Professional | TC | $58.88 | $64.57 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $165.96 / $257.04
| Professional | | $93.33 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $128.82 / $194.98
| Professional | 26 | $67.61 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $40.74 / $69.18
| Professional | TC | $22.91 | $40.74 | $69.18 |