- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $87.10
| Facility | 26 | $83.18 | $83.18 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $269.15 / $436.52
| Professional | | $169.82 | $269.15 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $67.61 / $186.21
| Professional | 26 | $52.48 | $67.61 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $295.12
| Professional | TC | $114.82 | $173.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $53.70
| Professional | 26 | $43.65 | $43.65 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $354.81 / $562.34
| Professional | | $165.96 | $354.81 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $123.03 / $204.17
| Professional | 26 | $57.54 | $123.03 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $346.74
| Professional | TC | $109.65 | $199.53 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $309.03 / $549.54
| Professional | | $204.17 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $134.90
| Professional | 26 | $57.54 | $79.43 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $245.47 / $436.52
| Professional | TC | $134.90 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Professional | 26 | $114.82 | $114.82 | $114.82 |
- 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
- $190.55 / $295.12 / $537.03
| Professional | | $190.55 | $295.12 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $125.89
| Professional | 26 | $57.54 | $70.79 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $223.87 / $426.58
| Professional | TC | $125.89 | $223.87 | $426.58 |