- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Facility | 26 | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $331.13 / $616.60
| Professional | | $269.15 | $331.13 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $48.98 / $93.33
| Professional | 26 | $38.90 | $48.98 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $281.84 / $524.81
| Professional | TC | $223.87 | $281.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $446.68 / $575.44
| Professional | | $302.00 | $446.68 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $67.61 / $89.13
| Professional | 26 | $45.71 | $67.61 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $371.54 / $501.19
| Professional | TC | $257.04 | $371.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $426.58 / $707.95
| Professional | | $398.11 | $426.58 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $107.15
| Professional | 26 | $57.54 | $70.79 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $371.54 / $602.56
| Professional | TC | $338.84 | $371.54 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $446.68 / $851.14
| Professional | | $380.19 | $446.68 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $67.61 / $128.82
| Professional | 26 | $57.54 | $67.61 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $316.23 / $380.19 / $724.44
| Professional | TC | $316.23 | $380.19 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $389.05 / $794.33
| Professional | | $269.15 | $389.05 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $57.54 / $120.23
| Professional | 26 | $41.69 | $57.54 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $338.84 / $660.69
| Professional | TC | $223.87 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $489.78 / $870.96
| Professional | | $380.19 | $489.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $69.18 / $102.33
| Professional | 26 | $57.54 | $69.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $316.23 / $416.87 / $575.44
| Professional | TC | $316.23 | $416.87 | $575.44 |