- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $380.19
| Professional | | $173.78 | $269.15 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $70.79 / $186.21
| Professional | 26 | $52.48 | $70.79 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $295.12
| Professional | TC | $114.82 | $181.97 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $181.97
| Professional | 26 | $44.67 | $44.67 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $407.38 / $588.84
| Professional | | $169.82 | $407.38 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $131.83 / $186.21
| Professional | 26 | $56.23 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $263.03 / $416.87
| Professional | TC | $112.20 | $263.03 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | 26 | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $407.38 / $758.58
| Professional | | $223.87 | $407.38 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $102.33 / $173.78
| Professional | 26 | $64.57 | $102.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $275.42 / $602.56
| Professional | TC | $151.36 | $275.42 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $309.03 / $478.63
| Professional | | $199.53 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $102.33 / $147.91
| Professional | 26 | $64.57 | $102.33 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $204.17 / $302.00
| Professional | TC | $131.83 | $204.17 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $338.84 / $616.60
| Professional | | $199.53 | $338.84 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $91.20 / $177.83
| Professional | 26 | $61.66 | $91.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $229.09 / $407.38
| Professional | TC | $134.90 | $229.09 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $47.86 / $57.54
| Facility | 26 | $42.66 | $47.86 | $57.54 |