- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 26 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $380.19
| Professional | | $114.82 | $173.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $52.48 / $169.82
| Professional | 26 | $34.67 | $52.48 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $134.90 / $275.42
| Professional | TC | $95.50 | $134.90 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $489.78
| Professional | | $169.82 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $70.79 / $138.04
| Professional | 26 | $38.90 | $70.79 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $190.55 / $380.19
| Professional | TC | $131.83 | $190.55 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 26 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $416.87 / $660.69
| Professional | | $181.97 | $416.87 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $107.15 / $186.21
| Professional | 26 | $46.77 | $107.15 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $478.63
| Professional | TC | $144.54 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $870.96
| Professional | | $645.65 | $645.65 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $151.36 / $204.17
| Professional | 26 | $138.04 | $151.36 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $436.52 / $489.78 / $660.69
| Professional | TC | $436.52 | $489.78 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $316.23 / $489.78
| Professional | | $165.96 | $316.23 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $60.26 / $138.04
| Professional | 26 | $37.15 | $60.26 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $380.19
| Professional | TC | $117.49 | $173.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $398.11 / $741.31
| Professional | | $204.17 | $398.11 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $112.20 / $208.93
| Professional | 26 | $60.26 | $112.20 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $281.84 / $537.03
| Professional | TC | $147.91 | $281.84 | $537.03 |