- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $338.84 / $588.84
| Professional | | $281.84 | $338.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $102.33 / $199.53
| Professional | 26 | $79.43 | $102.33 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $416.87
| Professional | TC | $199.53 | $245.47 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Professional | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | 26 | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $416.87 / $446.68
| Professional | | $128.82 | $416.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $131.83 / $131.83
| Professional | 26 | $112.20 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Professional | TC | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $346.74 / $977.24
| Professional | | $263.03 | $346.74 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $114.82 / $190.55
| Professional | 26 | $75.86 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $457.09
| Professional | TC | $173.78 | $251.19 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $229.09 / $257.04
| Facility | 26 | $93.33 | $229.09 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $346.74 / $602.56
| Professional | | $288.40 | $346.74 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $107.15 / $194.98
| Professional | 26 | $83.18 | $107.15 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $416.87
| Professional | TC | $199.53 | $245.47 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $295.12 / $371.54
| Professional | | $141.25 | $295.12 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $100.00 / $169.82
| Professional | 26 | $77.62 | $100.00 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $234.42 / $354.81
| Professional | TC | $147.91 | $234.42 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $371.54 / $478.63
| Professional | | $288.40 | $371.54 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $141.25
| Professional | 26 | $87.10 | $109.65 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $263.03 / $346.74
| Professional | TC | $194.98 | $263.03 | $346.74 |