- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Facility | 26 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $407.38 / $630.96
| Professional | | $251.19 | $407.38 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $109.65 / $181.97
| Professional | 26 | $69.18 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $281.84 / $457.09
| Professional | TC | $177.83 | $281.84 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $323.59 / $575.44
| Professional | | $239.88 | $323.59 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $79.43 / $109.65
| Professional | 26 | $67.61 | $79.43 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $245.47 / $436.52
| Professional | TC | $169.82 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $512.86 / $977.24
| Professional | | $288.40 | $512.86 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $83.18 / $177.83
| Professional | 26 | $58.88 | $83.18 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $416.87 / $831.76
| Professional | TC | $208.93 | $416.87 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | 26 | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $467.74 / $870.96
| Professional | | $263.03 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $81.28 / $144.54
| Professional | 26 | $56.23 | $81.28 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $371.54 / $794.33
| Professional | TC | $190.55 | $371.54 | $794.33 |