- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | 26 | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $302.00 / $691.83
| Professional | | $204.17 | $302.00 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $204.17
| Professional | 26 | $56.23 | $85.11 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $190.55 / $524.81
| Professional | TC | $147.91 | $190.55 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $389.05 / $707.95
| Professional | | $245.47 | $389.05 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $208.93
| Professional | 26 | $63.10 | $104.71 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $251.19 / $501.19
| Professional | TC | $165.96 | $251.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | 26 | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $602.56 / $954.99
| Professional | | $316.23 | $602.56 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $181.97 / $316.23
| Professional | 26 | $83.18 | $181.97 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $436.52 / $645.65
| Professional | TC | $229.09 | $436.52 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,202.26
| Professional | | $891.25 | $891.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $331.13
| Professional | 26 | $199.53 | $245.47 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $549.54 / $645.65 / $891.25
| Professional | TC | $549.54 | $645.65 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $436.52 / $676.08
| Professional | | $234.42 | $436.52 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $223.87
| Professional | 26 | $60.26 | $87.10 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $223.87 / $501.19
| Professional | TC | $158.49 | $223.87 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $562.34 / $707.95
| Professional | | $281.84 | $562.34 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $181.97 / $223.87
| Professional | 26 | $89.13 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $380.19 / $478.63
| Professional | TC | $199.53 | $380.19 | $478.63 |