- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | 26 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $275.42
| Professional | | $117.49 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $25.12 / $57.54
| Professional | 26 | $20.89 | $25.12 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $251.19
| Professional | TC | $93.33 | $123.03 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $138.04 / $194.98
| Professional | | $123.03 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $25.12 / $36.31
| Professional | 26 | $23.44 | $25.12 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $109.65 / $158.49
| Professional | TC | $100.00 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $371.54
| Professional | | $138.04 | $204.17 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $34.67 / $60.26
| Professional | 26 | $23.44 | $34.67 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $177.83 / $302.00
| Professional | TC | $112.20 | $177.83 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $223.87 / $346.74
| Professional | | $144.54 | $223.87 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $41.69 / $61.66
| Professional | 26 | $27.54 | $41.69 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $275.42
| Professional | TC | $117.49 | $181.97 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $223.87 / $446.68
| Professional | | $144.54 | $223.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $41.69 / $81.28
| Professional | 26 | $25.70 | $41.69 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $186.21 / $354.81
| Professional | TC | $117.49 | $186.21 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $21.38 / $23.44
| Facility | 26 | $16.22 | $21.38 | $23.44 |