- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $354.81
| Facility | 26 | $39.81 | $39.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $154.88 / $338.84
| Professional | | $125.89 | $154.88 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $50.12 / $128.82
| Professional | 26 | $38.90 | $50.12 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $173.78
| Professional | TC | $77.62 | $104.71 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $138.04 / $676.08
| Professional | | $45.71 | $138.04 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $52.48
| Professional | 26 | $40.74 | $40.74 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $128.82
| Professional | TC | $95.50 | $95.50 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $363.08
| Professional | | $141.25 | $204.17 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $58.88 / $114.82
| Professional | 26 | $42.66 | $58.88 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $141.25 / $263.03
| Professional | TC | $93.33 | $141.25 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $158.49 / $323.59
| Professional | | $134.90 | $158.49 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $46.77 / $93.33
| Professional | 26 | $39.81 | $46.77 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $229.09
| Professional | TC | $95.50 | $112.20 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $190.55 / $338.84
| Professional | | $125.89 | $190.55 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $120.23
| Professional | 26 | $38.90 | $58.88 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $134.90 / $281.84
| Professional | TC | $87.10 | $134.90 | $281.84 |