- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $363.08 / $724.44
| Professional | | $234.42 | $363.08 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $380.19
| Professional | 26 | $128.82 | $181.97 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $338.84
| Professional | TC | $109.65 | $181.97 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $398.11 / $588.84
| Professional | | $288.40 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $151.36 / $213.80 / $309.03
| Professional | 26 | $151.36 | $213.80 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $275.42
| Professional | TC | $138.04 | $190.55 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $407.38 / $870.96
| Professional | | $354.81 | $407.38 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $181.97 / $213.80 / $457.09
| Professional | 26 | $181.97 | $213.80 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $199.53 / $416.87
| Professional | TC | $177.83 | $199.53 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $575.44 / $912.01
| Professional | | $338.84 | $575.44 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $177.83 / $302.00 / $457.09
| Professional | 26 | $177.83 | $302.00 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $269.15 / $426.58
| Professional | TC | $162.18 | $269.15 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $398.11 / $1,047.13
| Professional | | $323.59 | $398.11 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $467.74
| Professional | 26 | $162.18 | $204.17 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $181.97 / $426.58
| Professional | TC | $154.88 | $181.97 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |