- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $281.84 / $436.52
| Professional | | $239.88 | $281.84 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $102.33 / $141.25
| Professional | 26 | $89.13 | $102.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $302.00
| Professional | TC | $141.25 | $181.97 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $354.81 / $562.34
| Professional | | $245.47 | $354.81 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $128.82 / $194.98
| Professional | 26 | $93.33 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $234.42 / $363.08
| Professional | TC | $158.49 | $234.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $398.11 / $616.60
| Professional | | $275.42 | $398.11 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $144.54 / $213.80
| Professional | 26 | $107.15 | $144.54 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $398.11
| Professional | TC | $169.82 | $257.04 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $512.86 / $3,890.45
| Professional | | $323.59 | $512.86 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $2,454.71
| Professional | 26 | $104.71 | $162.18 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $346.74 / $1,479.11
| Professional | TC | $223.87 | $346.74 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $323.59 / $467.74
| Professional | | $269.15 | $323.59 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $104.71 / $162.18
| Professional | 26 | $97.72 | $104.71 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $223.87 / $302.00
| Professional | TC | $165.96 | $223.87 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $398.11 / $630.96
| Professional | | $275.42 | $398.11 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $263.03
| Professional | 26 | $107.15 | $165.96 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $239.88 / $407.38
| Professional | TC | $165.96 | $239.88 | $407.38 |