- 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
- $338.84 / $407.38 / $831.76
| Professional | | $338.84 | $407.38 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $125.89 / $223.87
| Professional | 26 | $100.00 | $125.89 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $269.15 / $407.38
| Professional | TC | $229.09 | $269.15 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $512.86 / $741.31
| Professional | | $363.08 | $512.86 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $204.17
| Professional | 26 | $102.33 | $141.25 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $371.54 / $537.03
| Professional | TC | $257.04 | $371.54 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $512.86 / $707.95
| Professional | | $354.81 | $512.86 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $213.80
| Professional | 26 | $125.89 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $354.81 / $489.78
| Professional | TC | $223.87 | $354.81 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $891.25
| Professional | | $489.78 | $489.78 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $151.36 / $331.13
| Professional | 26 | $147.91 | $151.36 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $562.34
| Professional | TC | $338.84 | $338.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $363.08
| Professional | | $346.74 | $346.74 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $107.15 / $107.15
| Professional | 26 | $102.33 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $251.19
| Professional | TC | $239.88 | $239.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $489.78 / $741.31
| Professional | | $371.54 | $489.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $275.42
| Professional | 26 | $125.89 | $173.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $331.13 / $512.86
| Professional | TC | $234.42 | $331.13 | $512.86 |