- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Facility | 26 | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $158.49 / $239.88
| Professional | | $151.36 | $158.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $57.54 / $181.97
| Professional | 26 | $52.48 | $57.54 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $102.33 / $154.88
| Professional | TC | $95.50 | $102.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Professional | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $66.07 / $93.33
| Facility | 26 | $14.13 | $66.07 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $363.08 / $1,071.52
| Professional | | $275.42 | $363.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $75.86 / $275.42
| Professional | 26 | $54.95 | $75.86 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $295.12 / $758.58
| Professional | TC | $218.78 | $295.12 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $316.23 / $489.78
| Professional | | $234.42 | $316.23 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $66.07 / $100.00
| Professional | 26 | $47.86 | $66.07 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $257.04 / $398.11
| Professional | TC | $186.21 | $257.04 | $398.11 |