- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $398.11 / $912.01
| Professional | | $251.19 | $398.11 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $117.49 / $181.97
| Professional | 26 | $72.44 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $281.84 / $660.69
| Professional | TC | $186.21 | $281.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $363.08 / $912.01
| Professional | | $245.47 | $363.08 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $102.33 / $208.93
| Professional | 26 | $69.18 | $102.33 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $660.69
| Professional | TC | $177.83 | $263.03 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $575.44 / $977.24
| Professional | | $331.13 | $575.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $95.50 / $208.93
| Professional | 26 | $57.54 | $95.50 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $467.74 / $870.96
| Professional | TC | $234.42 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $371.54 / $707.95
| Professional | | $295.12 | $371.54 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $194.98
| Professional | 26 | $83.18 | $104.71 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $269.15 / $501.19
| Professional | TC | $213.80 | $269.15 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $501.19 / $1,023.29
| Professional | | $316.23 | $501.19 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $117.49 / $186.21
| Professional | 26 | $74.13 | $117.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $346.74 / $758.58
| Professional | TC | $223.87 | $346.74 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $489.78 / $977.24
| Professional | | $263.03 | $489.78 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $288.40
| Professional | 26 | $72.44 | $97.72 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $338.84 / $676.08
| Professional | TC | $199.53 | $338.84 | $676.08 |