- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $69.18
| Facility | 26 | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $223.87 / $467.74
| Professional | | $169.82 | $223.87 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $74.13 / $144.54
| Professional | 26 | $52.48 | $74.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $338.84
| Professional | TC | $114.82 | $154.88 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $245.47 / $630.96
| Professional | | $169.82 | $245.47 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $83.18 / $190.55
| Professional | 26 | $56.23 | $83.18 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $165.96 / $416.87
| Professional | TC | $112.20 | $165.96 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $363.08 / $645.65
| Professional | | $229.09 | $363.08 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $169.82
| Professional | 26 | $57.54 | $83.18 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $263.03 / $446.68
| Professional | TC | $154.88 | $263.03 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $478.63
| Professional | | $204.17 | $257.04 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $89.13 / $162.18
| Professional | 26 | $69.18 | $89.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $323.59
| Professional | TC | $134.90 | $169.82 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $295.12 / $616.60
| Professional | | $181.97 | $295.12 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $77.62 / $147.91
| Professional | 26 | $54.95 | $77.62 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $199.53 / $457.09
| Professional | TC | $123.03 | $199.53 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $309.03 / $549.54
| Professional | | $186.21 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $234.42
| Professional | 26 | $60.26 | $87.10 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $218.78 / $389.05
| Professional | TC | $131.83 | $218.78 | $389.05 |