- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Facility | 26 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $331.13 / $707.95
| Professional | | $181.97 | $331.13 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $89.13 / $269.15
| Professional | 26 | $53.70 | $89.13 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $239.88 / $380.19
| Professional | TC | $125.89 | $239.88 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $275.42 / $275.42
| Professional | | $89.13 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $112.20
| Facility | 26 | $89.13 | $89.13 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $338.84 / $524.81
| Professional | | $229.09 | $338.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $89.13 / $162.18
| Professional | 26 | $39.81 | $89.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $269.15 / $380.19
| Professional | TC | $123.03 | $269.15 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $316.23 / $575.44
| Professional | | $295.12 | $316.23 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $112.20
| Facility | 26 | $89.13 | $89.13 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $398.11 / $467.74
| Professional | | $275.42 | $398.11 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $89.13 / $131.83
| Professional | 26 | $58.88 | $89.13 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $223.87 / $295.12
| Professional | TC | $123.03 | $223.87 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $426.58
| Professional | | $169.82 | $263.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $53.70 / $134.90
| Professional | 26 | $52.48 | $53.70 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $199.53 / $323.59
| Professional | TC | $114.82 | $199.53 | $323.59 |