- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | 26 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $281.84 / $446.68
| Professional | | $239.88 | $281.84 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $100.00 / $158.49
| Professional | 26 | $89.13 | $100.00 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $181.97 / $309.03
| Professional | TC | $144.54 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $467.74 / $741.31
| Professional | | $309.03 | $467.74 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $257.04
| Professional | 26 | $102.33 | $154.88 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $295.12 / $489.78
| Professional | TC | $208.93 | $295.12 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $436.52 / $891.25
| Professional | | $234.42 | $436.52 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $165.96 / $295.12
| Professional | 26 | $112.20 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $275.42 / $588.84
| Professional | TC | $128.82 | $275.42 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $512.86 / $812.83
| Professional | | $338.84 | $512.86 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $165.96 / $269.15
| Professional | 26 | $112.20 | $165.96 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $346.74 / $537.03
| Professional | TC | $229.09 | $346.74 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $457.09 / $831.76
| Professional | | $275.42 | $457.09 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $288.40
| Professional | 26 | $112.20 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $316.23 / $537.03
| Professional | TC | $186.21 | $316.23 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $63.10 / $81.28
| Facility | 26 | $52.48 | $63.10 | $81.28 |