- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $5,495.41
| Facility | 26 | $89.13 | $89.13 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $354.81 / $691.83
| Professional | | $288.40 | $354.81 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $562.34
| Professional | TC | $245.47 | $309.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $363.08 / $676.08
| Professional | | $295.12 | $363.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $316.23 / $602.56
| Professional | TC | $263.03 | $316.23 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $50.12 / $72.44
| Facility | 26 | $10.72 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $426.58 / $776.25
| Professional | | $309.03 | $426.58 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $371.54 / $660.69
| Professional | TC | $263.03 | $371.54 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $199.53
| Facility | 26 | $102.33 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $407.38 / $2,344.23
| Professional | | $288.40 | $407.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $354.81 / $2,041.74
| Professional | TC | $251.19 | $354.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $354.81 / $660.69
| Professional | | $288.40 | $354.81 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $575.44
| Professional | TC | $245.47 | $309.03 | $575.44 |