- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Facility | 26 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $436.52
| Professional | | $169.82 | $263.03 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $63.10 / $117.49
| Professional | 26 | $51.29 | $63.10 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $186.21 / $389.05
| Professional | TC | $120.23 | $186.21 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $363.08 / $426.58
| Professional | | $251.19 | $363.08 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $109.65 / $128.82
| Professional | 26 | $77.62 | $109.65 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $295.12
| Professional | TC | $173.78 | $251.19 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $309.03 / $891.25
| Professional | | $169.82 | $309.03 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $79.43 / $128.82
| Professional | 26 | $43.65 | $79.43 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $223.87 / $794.33
| Professional | TC | $123.03 | $223.87 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $263.03 / $707.95
| Professional | | $173.78 | $263.03 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $61.66 / $87.10
| Professional | 26 | $46.77 | $61.66 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $190.55 / $630.96
| Professional | TC | $125.89 | $190.55 | $630.96 |