- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $549.54 / $549.54
| Facility | 26 | $107.15 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $371.54 / $1,659.59
| Professional | | $269.15 | $371.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $93.33 / $316.23
| Professional | 26 | $77.62 | $93.33 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $309.03 / $741.31
| Professional | TC | $169.82 | $309.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $436.52 / $724.44
| Professional | | $275.42 | $436.52 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $107.15 / $186.21
| Professional | 26 | $77.62 | $107.15 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $309.03 / $562.34
| Professional | TC | $190.55 | $309.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $616.60
| Professional | | $32.36 | $33.11 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | 26 | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $478.63 / $776.25
| Professional | | $398.11 | $478.63 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $141.25 / $213.80
| Professional | 26 | $120.23 | $141.25 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $338.84 / $575.44
| Professional | TC | $288.40 | $338.84 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $426.58 / $660.69
| Professional | | $251.19 | $426.58 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $177.83 / $269.15
| Professional | 26 | $81.28 | $177.83 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $398.11
| Professional | TC | $169.82 | $251.19 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $302.00 / $575.44
| Professional | | $123.03 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $380.19 / $660.69
| Professional | | $257.04 | $380.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $83.18 / $154.88
| Professional | 26 | $79.43 | $83.18 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $257.04 / $549.54
| Professional | TC | $177.83 | $257.04 | $549.54 |