- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Facility | 26 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $630.96
| Professional | | $245.47 | $309.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $100.00 / $177.83
| Professional | 26 | $52.48 | $100.00 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $234.42 / $524.81
| Professional | TC | $162.18 | $234.42 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $331.13 / $501.19
| Professional | | $234.42 | $331.13 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $67.61 / $114.82
| Professional | 26 | $50.12 | $67.61 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $257.04 / $398.11
| Professional | TC | $194.98 | $257.04 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $416.87 / $645.65
| Professional | | $295.12 | $416.87 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $93.33 / $138.04
| Professional | 26 | $60.26 | $93.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $331.13 / $501.19
| Professional | TC | $208.93 | $331.13 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $407.38 / $741.31
| Professional | | $302.00 | $407.38 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $83.18 / $151.36
| Professional | 26 | $63.10 | $83.18 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $323.59 / $588.84
| Professional | TC | $239.88 | $323.59 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $67.61
| Facility | 26 | $58.88 | $58.88 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $323.59 / $602.56
| Professional | | $251.19 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $83.18 / $151.36
| Professional | 26 | $56.23 | $83.18 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $467.74
| Professional | TC | $173.78 | $251.19 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $416.87 / $741.31
| Professional | | $257.04 | $416.87 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $91.20 / $165.96
| Professional | 26 | $56.23 | $91.20 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $323.59 / $588.84
| Professional | TC | $208.93 | $323.59 | $588.84 |