- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $354.81 / $354.81
| Facility | 26 | $87.10 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $436.52 / $1,737.80
| Professional | | $302.00 | $436.52 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $107.15 / $338.84
| Professional | 26 | $81.28 | $107.15 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $323.59 / $1,174.90
| Professional | TC | $239.88 | $323.59 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $489.78 / $489.78
| Professional | | $134.90 | $489.78 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $165.96
| Facility | 26 | $134.90 | $134.90 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $489.78 / $870.96
| Professional | | $302.00 | $489.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $131.83 / $239.88
| Professional | 26 | $60.26 | $131.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $354.81 / $630.96
| Professional | TC | $190.55 | $354.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $537.03 / $812.83
| Professional | | $512.86 | $537.03 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $165.96
| Facility | 26 | $134.90 | $134.90 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $691.83 / $870.96
| Professional | | $426.58 | $691.83 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $134.90 / $199.53
| Professional | 26 | $89.13 | $134.90 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $354.81 / $524.81
| Professional | TC | $245.47 | $354.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $323.59 / $870.96
| Professional | | $269.15 | $323.59 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $199.53
| Professional | 26 | $79.43 | $85.11 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $234.42 / $457.09
| Professional | TC | $190.55 | $234.42 | $457.09 |