- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $346.74
| Professional | | $120.23 | $147.91 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $81.28 / $194.98
| Professional | 26 | $67.61 | $81.28 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $61.66 / $95.50
| Professional | TC | $52.48 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $295.12 / $467.74
| Professional | | $177.83 | $295.12 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $181.97 / $281.84
| Professional | 26 | $104.71 | $181.97 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $114.82 / $181.97
| Professional | TC | $75.86 | $114.82 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $354.81 / $645.65
| Professional | | $131.83 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $213.80 / $398.11
| Professional | 26 | $75.86 | $213.80 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $141.25 / $245.47
| Professional | TC | $56.23 | $141.25 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $537.03 / $724.44
| Professional | | $295.12 | $537.03 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $407.38
| Professional | 26 | $144.54 | $316.23 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $229.09 / $302.00
| Professional | TC | $120.23 | $229.09 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $331.13 / $407.38
| Professional | | $177.83 | $331.13 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $141.25 / $281.84
| Professional | 26 | $75.86 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $102.33 / $181.97
| Professional | TC | $63.10 | $102.33 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $251.19 / $794.33
| Professional | | $138.04 | $251.19 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $144.54 / $489.78
| Professional | 26 | $79.43 | $144.54 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $144.54 / $316.23
| Professional | TC | $61.66 | $144.54 | $316.23 |