- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Facility | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $302.00
| Professional | | $112.20 | $147.91 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $25.70 / $57.54
| Professional | 26 | $19.95 | $25.70 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $117.49 / $251.19
| Professional | TC | $89.13 | $117.49 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $389.05
| Professional | | $131.83 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $33.11 / $77.62
| Professional | 26 | $22.39 | $33.11 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $316.23
| Professional | TC | $107.15 | $165.96 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Facility | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $338.84 / $512.86
| Professional | | $173.78 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $70.79 / $117.49
| Professional | 26 | $30.20 | $70.79 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $269.15 / $398.11
| Professional | TC | $141.25 | $269.15 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $676.08
| Professional | | $501.19 | $501.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $95.50 / $125.89
| Professional | 26 | $77.62 | $95.50 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $407.38 / $549.54
| Professional | TC | $323.59 | $407.38 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $251.19 / $380.19
| Professional | | $131.83 | $251.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $33.11 / $87.10
| Professional | 26 | $23.44 | $33.11 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $316.23
| Professional | TC | $97.72 | $141.25 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $302.00 / $676.08
| Professional | | $165.96 | $302.00 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $69.18 / $151.36
| Professional | 26 | $25.70 | $69.18 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $234.42 / $467.74
| Professional | TC | $147.91 | $234.42 | $467.74 |