- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Facility | 26 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $151.36 / $295.12
| Professional | | $128.82 | $151.36 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $50.12 / $151.36
| Professional | 26 | $40.74 | $50.12 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $208.93
| Professional | TC | $87.10 | $107.15 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $194.98 / $309.03
| Professional | | $154.88 | $194.98 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $97.72
| Professional | 26 | $52.48 | $64.57 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $134.90 / $208.93
| Professional | TC | $102.33 | $134.90 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $691.83
| Professional | | $32.36 | $33.11 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Facility | 26 | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $1,513.56
| Professional | | $204.17 | $269.15 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $89.13 / $117.49
| Professional | 26 | $63.10 | $89.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $977.24
| Professional | TC | $138.04 | $181.97 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $281.84
| Professional | | $131.83 | $208.93 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $67.61 / $93.33
| Professional | 26 | $42.66 | $67.61 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $141.25 / $177.83
| Professional | TC | $89.13 | $141.25 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $131.83 / $269.15
| Professional | | $54.95 | $131.83 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $251.19
| Professional | | $123.03 | $162.18 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $50.12 / $81.28
| Professional | 26 | $38.90 | $50.12 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $173.78
| Professional | TC | $81.28 | $104.71 | $173.78 |