- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $478.63
| Facility | 26 | $53.70 | $53.70 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $426.58
| Professional | | $107.15 | $138.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $147.91
| Professional | 26 | $52.48 | $64.57 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $60.26 / $144.54
| Professional | TC | $52.48 | $60.26 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $117.49 / $549.54
| Professional | | $56.23 | $117.49 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $60.26 / $74.13
| Professional | 26 | $58.88 | $60.26 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $72.44
| Professional | TC | $60.26 | $60.26 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $346.74
| Professional | | $114.82 | $181.97 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $72.44 / $138.04
| Professional | 26 | $54.95 | $72.44 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $95.50 / $199.53
| Professional | TC | $57.54 | $95.50 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $269.15
| Professional | | $117.49 | $138.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $131.83
| Professional | 26 | $54.95 | $64.57 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $72.44 / $141.25
| Professional | TC | $61.66 | $72.44 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $346.74
| Professional | | $107.15 | $169.82 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $74.13 / $165.96
| Professional | 26 | $51.29 | $74.13 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $100.00 / $186.21
| Professional | TC | $53.70 | $100.00 | $186.21 |