- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | 26 | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $407.38
| Professional | | $173.78 | $223.87 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $169.82
| Professional | 26 | $64.57 | $83.18 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $263.03
| Professional | TC | $109.65 | $147.91 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $275.42 / $549.54
| Professional | | $181.97 | $275.42 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $199.53
| Professional | 26 | $67.61 | $102.33 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $346.74
| Professional | TC | $117.49 | $173.78 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $302.00 / $457.09
| Professional | | $194.98 | $302.00 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $107.15 / $165.96
| Professional | 26 | $79.43 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $186.21 / $281.84
| Professional | TC | $104.71 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $302.00 / $524.81
| Professional | | $218.78 | $302.00 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $107.15 / $190.55
| Professional | 26 | $79.43 | $107.15 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $331.13
| Professional | TC | $138.04 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $234.42 / $426.58
| Professional | | $190.55 | $234.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $144.54
| Professional | 26 | $67.61 | $87.10 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $269.15
| Professional | TC | $114.82 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $302.00 / $524.81
| Professional | | $186.21 | $302.00 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $102.33 / $186.21
| Professional | 26 | $70.79 | $102.33 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $331.13
| Professional | TC | $114.82 | $194.98 | $331.13 |