- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | 26 | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $295.12 / $562.34
| Professional | | $218.78 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $112.20 / $239.88
| Professional | 26 | $77.62 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $177.83 / $331.13
| Professional | TC | $138.04 | $177.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $346.74 / $691.83
| Professional | | $234.42 | $346.74 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $123.03 / $239.88
| Professional | 26 | $81.28 | $123.03 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $446.68
| Professional | TC | $151.36 | $229.09 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $371.54 / $562.34
| Professional | | $275.42 | $371.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $199.53
| Professional | 26 | $104.71 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $234.42 / $363.08
| Professional | TC | $147.91 | $234.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $354.81 / $660.69
| Professional | | $257.04 | $354.81 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $234.42
| Professional | 26 | $95.50 | $128.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $245.47 / $436.52
| Professional | TC | $186.21 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $295.12 / $562.34
| Professional | | $239.88 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $102.33 / $194.98
| Professional | 26 | $81.28 | $102.33 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $186.21 / $371.54
| Professional | TC | $154.88 | $186.21 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $371.54 / $660.69
| Professional | | $229.09 | $371.54 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $123.03 / $223.87
| Professional | 26 | $85.11 | $123.03 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $239.88 / $426.58
| Professional | TC | $147.91 | $239.88 | $426.58 |