- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | 26 | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $524.81 / $1,096.48
| Professional | | $389.05 | $524.81 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $239.88 / $562.34
| Professional | 26 | $190.55 | $239.88 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $281.84 / $602.56
| Professional | TC | $213.80 | $281.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $676.08 / $912.01
| Professional | | $489.78 | $676.08 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $316.23 / $398.11
| Professional | 26 | $223.87 | $316.23 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $354.81 / $416.87
| Professional | TC | $263.03 | $354.81 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $891.25 / $1,318.26
| Professional | | $588.84 | $891.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $269.15 / $309.03 / $549.54
| Professional | 26 | $269.15 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $478.63 / $912.01
| Professional | TC | $309.03 | $478.63 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $724.44 / $1,380.38
| Professional | | $602.56 | $724.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $281.84 / $331.13 / $645.65
| Professional | 26 | $281.84 | $331.13 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $389.05 / $758.58
| Professional | TC | $323.59 | $389.05 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $1,202.26
| Professional | | $467.74 | $588.84 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $263.03 / $524.81
| Professional | 26 | $199.53 | $263.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $331.13 / $630.96
| Professional | TC | $245.47 | $331.13 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $741.31 / $1,380.38
| Professional | | $602.56 | $741.31 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $269.15 / $323.59 / $588.84
| Professional | 26 | $269.15 | $323.59 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $398.11 / $741.31
| Professional | TC | $323.59 | $398.11 | $741.31 |