- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $165.96 / $331.13
| Professional | | $131.83 | $165.96 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $83.18 / $173.78
| Professional | 26 | $72.44 | $83.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $81.28 / $144.54
| Professional | TC | $56.23 | $81.28 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $70.79 / $70.79
| Facility | 26 | $58.88 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $389.05 / $549.54
| Professional | | $223.87 | $389.05 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $199.53 / $281.84
| Professional | 26 | $114.82 | $199.53 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $204.17 / $269.15
| Professional | TC | $112.20 | $204.17 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $295.12 / $707.95
| Facility | 26 | $208.93 | $295.12 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $426.58 / $676.08
| Professional | | $251.19 | $426.58 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $213.80 / $338.84
| Professional | 26 | $128.82 | $213.80 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $208.93 / $331.13
| Professional | TC | $125.89 | $208.93 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $281.84 / $549.54
| Facility | 26 | $229.09 | $281.84 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $398.11 / $602.56
| Professional | | $275.42 | $398.11 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $199.53 / $309.03
| Professional | 26 | $141.25 | $199.53 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $194.98 / $302.00
| Professional | TC | $138.04 | $194.98 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $346.74 / $1,047.13
| Professional | | $162.18 | $346.74 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $165.96 / $512.86
| Professional | 26 | $85.11 | $165.96 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $177.83 / $549.54
| Professional | TC | $81.28 | $177.83 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $331.13 / $588.84
| Professional | | $162.18 | $331.13 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $162.18 / $281.84
| Professional | 26 | $85.11 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $165.96 / $302.00
| Professional | TC | $81.28 | $165.96 | $302.00 |