- 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
- $112.20 / $138.04 / $331.13
| Professional | | $112.20 | $138.04 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $46.77 / $131.83
| Professional | 26 | $39.81 | $46.77 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $154.88
| Professional | TC | $67.61 | $85.11 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $114.82 / $123.03
| Professional | | $112.20 | $114.82 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $213.80
| Professional | | $93.33 | $117.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $42.66 / $79.43
| Professional | 26 | $34.67 | $42.66 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $72.44 / $134.90
| Professional | TC | $58.88 | $72.44 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $50.12 / $70.79
| Facility | 26 | $10.72 | $50.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $309.03
| Professional | | $109.65 | $158.49 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $56.23 / $97.72
| Professional | 26 | $41.69 | $56.23 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $199.53
| Professional | TC | $67.61 | $102.33 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $199.53
| Facility | 26 | $102.33 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $954.99
| Professional | | $109.65 | $165.96 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $58.88 / $389.05
| Professional | 26 | $39.81 | $58.88 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $114.82 / $776.25
| Professional | TC | $67.61 | $114.82 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $141.25 / $257.04
| Professional | | $104.71 | $141.25 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $48.98 / $89.13
| Professional | 26 | $38.90 | $48.98 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $162.18
| Professional | TC | $67.61 | $93.33 | $162.18 |