- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $144.54 / $380.19
| Professional | | $83.18 | $144.54 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $41.69 / $128.82
| Professional | 26 | $28.84 | $41.69 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $93.33 / $251.19
| Professional | TC | $57.54 | $93.33 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $371.54
| Professional | | $154.88 | $154.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $138.04
| Professional | 26 | $131.83 | $131.83 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $229.09
| Professional | TC | $23.44 | $23.44 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $346.74 / $446.68
| Professional | | $114.82 | $346.74 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $102.33 / $138.04
| Professional | 26 | $41.69 | $102.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $245.47 / $316.23
| Professional | TC | $66.07 | $245.47 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $954.99
| Professional | | $549.54 | $549.54 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $158.49 / $338.84
| Professional | 26 | $147.91 | $158.49 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $371.54 / $398.11 / $602.56
| Professional | TC | $371.54 | $398.11 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $371.54
| Professional | | $102.33 | $154.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $53.70 / $138.04
| Professional | 26 | $37.15 | $53.70 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $66.07 / $229.09
| Professional | TC | $23.44 | $66.07 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $446.68 / $1,698.24
| Professional | | $117.49 | $446.68 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $165.96 / $630.96
| Professional | 26 | $56.23 | $165.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $275.42 / $1,047.13
| Professional | TC | $63.10 | $275.42 | $1,047.13 |