- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | 26 | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $269.15
| Professional | | $128.82 | $165.96 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $81.28 / $134.90
| Professional | 26 | $66.07 | $81.28 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $134.90
| Professional | TC | $57.54 | $83.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $363.08 / $537.03
| Professional | | $213.80 | $363.08 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $186.21 / $288.40
| Professional | 26 | $107.15 | $186.21 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $173.78 / $251.19
| Professional | TC | $107.15 | $173.78 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | 26 | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $416.87 / $724.44
| Professional | | $154.88 | $416.87 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $218.78 / $398.11
| Professional | 26 | $75.86 | $218.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $190.55 / $323.59
| Professional | TC | $75.86 | $190.55 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $645.65 / $851.14
| Professional | | $346.74 | $645.65 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $323.59 / $416.87
| Professional | 26 | $147.91 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $323.59 / $407.38
| Professional | TC | $162.18 | $323.59 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $398.11 / $489.78
| Professional | | $213.80 | $398.11 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $144.54 / $288.40
| Professional | 26 | $77.62 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $144.54 / $251.19
| Professional | TC | $85.11 | $144.54 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $407.38 / $870.96
| Professional | | $138.04 | $407.38 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $204.17 / $457.09
| Professional | 26 | $79.43 | $204.17 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $204.17 / $407.38
| Professional | TC | $70.79 | $204.17 | $407.38 |