- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | 26 | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $288.40 / $630.96
| Professional | | $218.78 | $288.40 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $190.55
| Professional | 26 | $67.61 | $93.33 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $204.17 / $416.87
| Professional | TC | $144.54 | $204.17 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $812.83
| Professional | | $218.78 | $323.59 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $109.65 / $223.87
| Professional | 26 | $74.13 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $537.03
| Professional | TC | $144.54 | $213.80 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $426.58 / $724.44
| Professional | | $295.12 | $426.58 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $208.93
| Professional | 26 | $69.18 | $107.15 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $309.03 / $501.19
| Professional | TC | $194.98 | $309.03 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $338.84 / $630.96
| Professional | | $263.03 | $338.84 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $112.20 / $208.93
| Professional | 26 | $89.13 | $112.20 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $416.87
| Professional | TC | $177.83 | $223.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | 26 | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $354.81 / $691.83
| Professional | | $234.42 | $354.81 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $95.50 / $181.97
| Professional | 26 | $67.61 | $95.50 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $537.03
| Professional | TC | $162.18 | $251.19 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $380.19 / $758.58
| Professional | | $223.87 | $380.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $112.20 / $309.03
| Professional | 26 | $79.43 | $112.20 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $275.42 / $467.74
| Professional | TC | $162.18 | $275.42 | $467.74 |