- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | 26 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $120.23 / $245.47
| Professional | | $83.18 | $120.23 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $70.79 / $169.82
| Professional | 26 | $53.70 | $70.79 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $46.77 / $95.50
| Professional | TC | $25.70 | $46.77 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $120.23 / $302.00
| Professional | | $95.50 | $120.23 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $79.43 / $204.17
| Professional | 26 | $56.23 | $79.43 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $44.67 / $109.65
| Professional | TC | $28.84 | $44.67 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | 26 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $239.88 / $331.13
| Professional | | $107.15 | $239.88 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $147.91 / $204.17
| Professional | 26 | $63.10 | $147.91 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $95.50 / $144.54
| Professional | TC | $46.77 | $95.50 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $389.05 / $446.68
| Professional | | $151.36 | $389.05 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $199.53 / $288.40
| Professional | 26 | $91.20 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $109.65 / $190.55
| Professional | TC | $38.90 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $269.15
| Professional | | $91.20 | $128.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $75.86 / $204.17
| Professional | 26 | $54.95 | $75.86 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $44.67 / $95.50
| Professional | TC | $26.30 | $44.67 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $213.80 / $331.13
| Professional | | $87.10 | $213.80 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $144.54 / $245.47
| Professional | 26 | $57.54 | $144.54 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $67.61 / $112.20
| Professional | TC | $27.54 | $67.61 | $112.20 |