- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 26 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $407.38 / $954.99
| Professional | | $346.74 | $407.38 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $223.87
| Professional | 26 | $109.65 | $120.23 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $295.12 / $380.19
| Professional | TC | $229.09 | $295.12 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $831.76 / $1,819.70
| Professional | | $407.38 | $831.76 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $288.40 / $288.40
| Professional | TC | $269.15 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $426.58 / $1,148.15
| Professional | | $346.74 | $426.58 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $302.00
| Professional | 26 | $107.15 | $138.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $288.40 / $851.14
| Professional | TC | $234.42 | $288.40 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $380.19 / $870.96
| Professional | | $363.08 | $380.19 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $114.82 / $234.42
| Professional | 26 | $109.65 | $114.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $263.03 / $630.96
| Professional | TC | $251.19 | $263.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $512.86 / $1,000.00
| Professional | | $302.00 | $512.86 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $269.15
| Professional | 26 | $95.50 | $154.88 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $354.81 / $724.44
| Professional | TC | $208.93 | $354.81 | $724.44 |