- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $25.70
| Facility | 26 | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $281.84
| Professional | | $114.82 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $23.99 / $52.48
| Professional | 26 | $20.89 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $199.53
| Professional | TC | $93.33 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $275.42
| Professional | | $109.65 | $154.88 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $29.51 / $50.12
| Professional | 26 | $21.38 | $29.51 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $125.89 / $229.09
| Professional | TC | $93.33 | $125.89 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $302.00
| Professional | | $138.04 | $190.55 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $30.90 / $54.95
| Professional | 26 | $21.88 | $30.90 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $162.18 / $245.47
| Professional | TC | $100.00 | $162.18 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $194.98 / $354.81
| Professional | | $144.54 | $194.98 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $36.31 / $66.07
| Professional | 26 | $27.54 | $36.31 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $154.88 / $288.40
| Professional | TC | $117.49 | $154.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $338.84
| Professional | | $117.49 | $181.97 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $28.18 / $57.54
| Professional | 26 | $20.42 | $28.18 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $151.36 / $281.84
| Professional | TC | $93.33 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $181.97 / $354.81
| Professional | | $125.89 | $181.97 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $35.48 / $57.54
| Professional | 26 | $23.44 | $35.48 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $263.03
| Professional | TC | $102.33 | $151.36 | $263.03 |