- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | 26 | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $169.82 / $363.08
| Professional | | $131.83 | $169.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $83.18 / $194.98
| Professional | 26 | $74.13 | $83.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $131.83
| Professional | TC | $57.54 | $83.18 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $104.71
| Professional | 26 | $81.28 | $81.28 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $229.09 / $245.47
| Professional | | $117.49 | $229.09 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | 26 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $194.98
| Professional | | $72.44 | $102.33 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $213.80 / $630.96
| Professional | | $125.89 | $213.80 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $102.33 / $323.59
| Professional | 26 | $60.26 | $102.33 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $316.23
| Professional | TC | $63.10 | $109.65 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $190.55 / $223.87
| Facility | 26 | $77.62 | $190.55 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $323.59
| Professional | | $134.90 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $91.20 / $169.82
| Professional | 26 | $75.86 | $91.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $85.11 / $158.49
| Professional | TC | $58.88 | $85.11 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $208.93 / $331.13
| Professional | | $125.89 | $208.93 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $97.72 / $173.78
| Professional | 26 | $69.18 | $97.72 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $100.00 / $169.82
| Professional | TC | $66.07 | $100.00 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $245.47
| Professional | | $123.03 | $165.96 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $91.20 / $131.83
| Professional | 26 | $72.44 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $83.18 / $123.03
| Professional | TC | $39.81 | $83.18 | $123.03 |