- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Facility | 26 | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $338.84 / $794.33
| Professional | | $181.97 | $338.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $93.33 / $288.40
| Professional | 26 | $53.70 | $93.33 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $229.09 / $426.58
| Professional | TC | $123.03 | $229.09 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $275.42 / $275.42
| Professional | | $91.20 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $112.20
| Facility | 26 | $91.20 | $91.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $338.84 / $537.03
| Professional | | $229.09 | $338.84 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $91.20 / $162.18
| Professional | 26 | $40.74 | $91.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $269.15 / $380.19
| Professional | TC | $123.03 | $269.15 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $323.59 / $549.54
| Professional | | $295.12 | $323.59 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $112.20
| Facility | 26 | $91.20 | $91.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $398.11 / $478.63
| Professional | | $275.42 | $398.11 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $91.20 / $131.83
| Professional | 26 | $58.88 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $223.87 / $295.12
| Professional | TC | $125.89 | $223.87 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $416.87
| Professional | | $169.82 | $263.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $53.70 / $131.83
| Professional | 26 | $52.48 | $53.70 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $199.53 / $331.13
| Professional | TC | $117.49 | $199.53 | $331.13 |