- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $446.68 / $794.33
| Professional | | $275.42 | $446.68 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $131.83 / $223.87
| Professional | 26 | $79.43 | $131.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $309.03 / $562.34
| Professional | TC | $186.21 | $309.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $66.07 / $104.71
| Professional | 26 | $60.26 | $66.07 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $323.59 / $380.19
| Professional | | $117.49 | $323.59 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $85.11 / $109.65
| Professional | 26 | $60.26 | $85.11 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $234.42 / $275.42
| Professional | TC | $85.11 | $234.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $501.19 / $891.25
| Professional | | $269.15 | $501.19 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $123.03 / $213.80
| Professional | 26 | $69.18 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $371.54 / $676.08
| Professional | TC | $204.17 | $371.54 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $346.74 / $794.33
| Professional | | $245.47 | $346.74 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $89.13 / $169.82
| Professional | 26 | $67.61 | $89.13 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $245.47 / $676.08
| Professional | TC | $173.78 | $245.47 | $676.08 |