- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $165.96
| Facility | 26 | $109.65 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $338.84 / $489.78
| Professional | | $257.04 | $338.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $251.19
| Professional | 26 | $67.61 | $102.33 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $223.87 / $323.59
| Professional | TC | $162.18 | $223.87 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $354.81 / $457.09
| Professional | | $309.03 | $354.81 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $117.49 / $147.91
| Professional | 26 | $102.33 | $117.49 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $234.42 / $302.00
| Professional | TC | $208.93 | $234.42 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $426.58 / $660.69
| Professional | | $288.40 | $426.58 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $141.25 / $213.80
| Professional | 26 | $87.10 | $141.25 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $288.40 / $446.68
| Professional | TC | $190.55 | $288.40 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $363.08 / $630.96
| Professional | | $302.00 | $363.08 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $199.53
| Professional | 26 | $93.33 | $117.49 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $436.52
| Professional | TC | $199.53 | $245.47 | $436.52 |