- 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
- $107.15 / $125.89 / $338.84
| Professional | | $107.15 | $125.89 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $61.66 / $123.03
| Professional | 26 | $53.70 | $61.66 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $61.66 / $141.25
| Professional | TC | $52.48 | $61.66 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $67.61 / $95.50
| Facility | 26 | $14.45 | $67.61 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $173.78 / $891.25
| Professional | | $107.15 | $173.78 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $83.18 / $295.12
| Professional | 26 | $56.23 | $83.18 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $104.71 / $389.05
| Professional | TC | $52.48 | $104.71 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $331.13
| Professional | | $102.33 | $165.96 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $67.61 / $107.15
| Professional | 26 | $52.48 | $67.61 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $95.50 / $208.93
| Professional | TC | $47.86 | $95.50 | $208.93 |