- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $501.19
| Facility | 26 | $56.23 | $56.23 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $724.44
| Professional | | $204.17 | $288.40 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $123.03 / $204.17
| Professional | 26 | $57.54 | $123.03 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $309.03
| Professional | TC | $147.91 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $218.78 / $741.31
| Professional | | $63.10 | $218.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $67.61
| Professional | 26 | $57.54 | $57.54 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $177.83 / $190.55
| Professional | TC | $162.18 | $177.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $288.40 / $562.34
| Professional | | $223.87 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $81.28 / $162.18
| Professional | 26 | $58.88 | $81.28 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $204.17 / $389.05
| Professional | TC | $154.88 | $204.17 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $257.04 / $512.86
| Professional | | $213.80 | $257.04 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $66.07 / $131.83
| Professional | 26 | $56.23 | $66.07 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $389.05
| Professional | TC | $162.18 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $309.03 / $575.44
| Professional | | $190.55 | $309.03 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $81.28 / $144.54
| Professional | 26 | $53.70 | $81.28 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $234.42 / $436.52
| Professional | TC | $134.90 | $234.42 | $436.52 |