- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $489.78
| Facility | 26 | $53.70 | $53.70 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $177.83 / $354.81
| Professional | | $151.36 | $177.83 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $60.26 / $151.36
| Professional | 26 | $52.48 | $60.26 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $177.83
| Professional | TC | $95.50 | $114.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $302.00 / $954.99
| Professional | | $54.95 | $302.00 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $64.57 / $74.13
| Professional | 26 | $58.88 | $64.57 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $295.12
| Professional | TC | $269.15 | $269.15 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $371.54 / $741.31
| Professional | | $269.15 | $371.54 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $69.18 / $134.90
| Professional | 26 | $53.70 | $69.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $302.00 / $602.56
| Professional | TC | $218.78 | $302.00 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $354.81 / $776.25
| Professional | | $302.00 | $354.81 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $128.82
| Professional | 26 | $54.95 | $64.57 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $295.12 / $645.65
| Professional | TC | $245.47 | $295.12 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $354.81 / $977.24
| Professional | | $245.47 | $354.81 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $74.13 / $165.96
| Professional | 26 | $48.98 | $74.13 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $288.40 / $741.31
| Professional | TC | $186.21 | $288.40 | $741.31 |