- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $194.98 / $524.81
| Facility | 26 | $72.44 | $194.98 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $275.42 / $630.96
| Professional | | $173.78 | $275.42 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $93.33 / $213.80
| Professional | 26 | $72.44 | $93.33 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $281.84
| Professional | TC | $95.50 | $128.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $234.42 / $2,691.53
| Professional | | $95.50 | $234.42 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | 26 | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $151.36 / $181.97
| Professional | TC | $134.90 | $151.36 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $269.15 / $549.54
| Professional | | $169.82 | $269.15 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $102.33 / $234.42
| Professional | 26 | $64.57 | $102.33 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $346.74
| Professional | TC | $102.33 | $158.49 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $436.52
| Professional | | $177.83 | $208.93 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $87.10 / $181.97
| Professional | 26 | $74.13 | $87.10 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $120.23 / $257.04
| Professional | TC | $102.33 | $120.23 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $302.00 / $1,412.54
| Professional | | $95.50 | $302.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $199.53 / $512.86
| Professional | 26 | $79.43 | $199.53 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $912.01
| Professional | TC | $95.50 | $141.25 | $912.01 |