- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $173.78 / $323.59
| Professional | | $144.54 | $173.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $85.11 / $199.53
| Professional | 26 | $75.86 | $85.11 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $93.33 / $128.82
| Professional | TC | $57.54 | $93.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $218.78 / $218.78
| Professional | | $186.21 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $288.40
| Professional | 26 | $120.23 | $120.23 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | TC | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $223.87 / $389.05
| Professional | | $125.89 | $223.87 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $109.65 / $186.21
| Professional | 26 | $83.18 | $109.65 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $109.65 / $177.83
| Professional | TC | $37.15 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $234.42 / $588.84
| Professional | | $199.53 | $234.42 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $288.40
| Professional | 26 | $97.72 | $114.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $120.23
| Professional | TC | $100.00 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $245.47 / $537.03
| Professional | | $158.49 | $245.47 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $199.53
| Professional | 26 | $91.20 | $117.49 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $128.82 / $234.42
| Professional | TC | $52.48 | $128.82 | $234.42 |