- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $380.19 / $933.25
| Professional | | $245.47 | $380.19 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $208.93
| Professional | 26 | $64.57 | $104.71 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $275.42 / $707.95
| Professional | TC | $181.97 | $275.42 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $758.58 / $891.25
| Professional | | $331.13 | $758.58 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $125.89 / $269.15
| Professional | 26 | $53.70 | $125.89 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $549.54 / $676.08
| Professional | TC | $245.47 | $549.54 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $660.69 / $1,445.44
| Professional | | $389.05 | $660.69 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $190.55 / $467.74
| Professional | 26 | $102.33 | $190.55 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $467.74 / $1,000.00
| Professional | TC | $302.00 | $467.74 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,000.00 / $1,621.81
| Professional | | $933.25 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $257.04 / $426.58
| Professional | 26 | $229.09 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $691.83 / $776.25 / $1,202.26
| Professional | TC | $691.83 | $776.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $588.84 / $891.25
| Professional | | $398.11 | $588.84 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $204.17 / $269.15
| Professional | 26 | $64.57 | $204.17 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $549.54 / $870.96
| Professional | TC | $186.21 | $549.54 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $741.31 / $2,691.53
| Professional | | $269.15 | $741.31 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $190.55 / $562.34
| Professional | 26 | $70.79 | $190.55 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $549.54 / $2,041.74
| Professional | TC | $234.42 | $549.54 | $2,041.74 |