- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | 26 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $295.12 / $562.34
| Professional | | $223.87 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $91.20 / $208.93
| Professional | 26 | $74.13 | $91.20 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $323.59
| Professional | TC | $158.49 | $218.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $309.03 / $549.54
| Professional | | $218.78 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $173.78
| Professional | 26 | $72.44 | $102.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $199.53 / $371.54
| Professional | TC | $144.54 | $199.53 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $426.58
| Professional | | $32.36 | $33.11 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | 26 | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $389.05 / $602.56
| Professional | | $331.13 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $190.55
| Professional | 26 | $114.82 | $134.90 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $251.19 / $416.87
| Professional | TC | $213.80 | $251.19 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $354.81 / $537.03
| Professional | | $218.78 | $354.81 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $169.82 / $204.17
| Professional | 26 | $79.43 | $169.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $295.12
| Professional | TC | $141.25 | $186.21 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $234.42 / $446.68
| Professional | | $114.82 | $234.42 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $263.03 / $501.19
| Professional | | $213.80 | $263.03 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $75.86 / $147.91
| Professional | 26 | $70.79 | $75.86 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $331.13
| Professional | TC | $138.04 | $181.97 | $331.13 |