- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | 26 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $467.74
| Professional | | $128.82 | $158.49 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $85.11 / $263.03
| Professional | 26 | $72.44 | $85.11 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $177.83
| Professional | TC | $54.95 | $83.18 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $223.87 / $371.54
| Professional | | $151.36 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $190.55
| Professional | 26 | $93.33 | $112.20 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $102.33 / $162.18
| Professional | TC | $51.29 | $102.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $269.15
| Professional | | $32.36 | $33.11 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $338.84
| Professional | | $154.88 | $229.09 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $112.20 / $223.87
| Professional | 26 | $77.62 | $112.20 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $102.33 / $158.49
| Professional | TC | $79.43 | $102.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $380.19
| Professional | | $154.88 | $251.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $131.83 / $204.17
| Professional | 26 | $79.43 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $117.49 / $138.04
| Professional | TC | $74.13 | $117.49 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $138.04 / $309.03
| Professional | | $85.11 | $138.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $186.21 / $281.84
| Professional | | $128.82 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $91.20 / $141.25
| Professional | 26 | $70.79 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $91.20 / $144.54
| Professional | TC | $45.71 | $91.20 | $144.54 |