- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | 26 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $177.83 / $346.74
| Professional | | $151.36 | $177.83 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $61.66 / $125.89
| Professional | 26 | $52.48 | $61.66 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $177.83
| Professional | TC | $93.33 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $338.84 / $338.84
| Professional | | $158.49 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $58.88 / $74.13
| Professional | 26 | $54.95 | $58.88 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $275.42 / $275.42
| Professional | TC | $102.33 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $436.52 / $741.31
| Professional | | $295.12 | $436.52 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $83.18 / $141.25
| Professional | 26 | $58.88 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $354.81 / $602.56
| Professional | TC | $234.42 | $354.81 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $288.40 / $602.56
| Professional | | $245.47 | $288.40 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $97.72 / $151.36
| Professional | 26 | $85.11 | $97.72 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $186.21 / $446.68
| Professional | TC | $162.18 | $186.21 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $173.78 / $512.86
| Professional | | $169.82 | $173.78 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $60.26 / $107.15
| Professional | 26 | $57.54 | $60.26 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $114.82 / $416.87
| Professional | TC | $112.20 | $114.82 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $426.58 / $676.08
| Professional | | $316.23 | $426.58 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $95.50 / $147.91
| Professional | 26 | $60.26 | $95.50 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $346.74 / $549.54
| Professional | TC | $257.04 | $346.74 | $549.54 |