- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | 26 | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $436.52 / $812.83
| Professional | | $275.42 | $436.52 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $114.82 / $251.19
| Professional | 26 | $67.61 | $114.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $331.13 / $512.86
| Professional | TC | $204.17 | $331.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $436.52 / $707.95
| Professional | | $302.00 | $436.52 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $120.23 / $223.87
| Professional | 26 | $67.61 | $120.23 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $302.00 / $478.63
| Professional | TC | $234.42 | $302.00 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $537.03 / $954.99
| Professional | | $398.11 | $537.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $162.18
| Professional | 26 | $69.18 | $93.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $316.23 / $436.52 / $794.33
| Professional | TC | $316.23 | $436.52 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | 26 | $134.90 | $134.90 | $134.90 |
- 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
- $380.19 / $524.81 / $891.25
| Professional | | $380.19 | $524.81 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $144.54
| Professional | 26 | $67.61 | $85.11 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $457.09 / $776.25
| Professional | TC | $302.00 | $457.09 | $776.25 |