- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $204.17 / $204.17
| Facility | 26 | $89.13 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $398.11
| Professional | | $109.65 | $162.18 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $147.91
| Professional | 26 | $54.95 | $69.18 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $147.91
| Professional | TC | $52.48 | $64.57 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $131.83 / $186.21
| Professional | | $120.23 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $64.57 / $93.33
| Professional | 26 | $60.26 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $64.57 / $93.33
| Professional | TC | $61.66 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $354.81
| Professional | | $131.83 | $208.93 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $91.20 / $154.88
| Professional | 26 | $61.66 | $91.20 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $104.71 / $234.42
| Professional | TC | $66.07 | $104.71 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $323.59
| Professional | | $131.83 | $199.53 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $107.15 / $165.96
| Professional | 26 | $70.79 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $169.82
| Professional | TC | $72.44 | $102.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $229.09 / $416.87
| Professional | | $141.25 | $229.09 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $104.71 / $204.17
| Professional | 26 | $67.61 | $104.71 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $120.23 / $208.93
| Professional | TC | $70.79 | $120.23 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $47.86 / $51.29
| Facility | 26 | $40.74 | $47.86 | $51.29 |