- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | 26 | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $346.74 / $1,174.90
| Professional | | $204.17 | $346.74 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $117.49 / $295.12
| Professional | 26 | $61.66 | $117.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $239.88 / $758.58
| Professional | TC | $128.82 | $239.88 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $295.12 / $295.12
| Professional | | $102.33 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $125.89
| Facility | 26 | $102.33 | $102.33 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $331.13 / $549.54
| Professional | | $223.87 | $331.13 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $102.33 / $181.97
| Professional | 26 | $45.71 | $102.33 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $229.09 / $380.19
| Professional | TC | $128.82 | $229.09 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $338.84 / $489.78
| Professional | | $323.59 | $338.84 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $125.89
| Facility | 26 | $102.33 | $102.33 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $416.87 / $512.86
| Professional | | $281.84 | $416.87 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $147.91
| Professional | 26 | $67.61 | $102.33 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $213.80 / $295.12
| Professional | TC | $131.83 | $213.80 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $257.04 / $501.19
| Professional | | $173.78 | $257.04 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $69.18 / $151.36
| Professional | 26 | $60.26 | $69.18 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $354.81
| Professional | TC | $114.82 | $194.98 | $354.81 |