- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $25.70
| Facility | 26 | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $151.36 / $251.19
| Professional | | $128.82 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $123.03 / $186.21
| Professional | TC | $102.33 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $131.83 / $323.59
| Professional | TC | $39.81 | $131.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $186.21 / $389.05
| Professional | | $89.13 | $186.21 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $154.88 / $323.59
| Professional | TC | $48.98 | $154.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $162.18 / $162.18
| Professional | | $128.82 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $45.71 / $45.71
| Professional | 26 | $37.15 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $158.49 / $338.84
| Professional | | $28.84 | $158.49 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $302.00
| Professional | | $95.50 | $147.91 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $123.03 / $245.47
| Professional | TC | $69.18 | $123.03 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $1,479.11
| Professional | | $954.99 | $954.99 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $1,288.25
| Professional | TC | $794.33 | $794.33 | $1,288.25 |