- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $141.25 / $173.78
| Facility | 26 | $109.65 | $141.25 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $524.81 / $1,819.70
| Professional | | $331.13 | $524.81 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $194.98 / $426.58
| Professional | 26 | $109.65 | $194.98 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $707.95
| Professional | TC | $218.78 | $323.59 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $239.88 / $295.12
| Professional | | $141.25 | $239.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $107.15 / $199.53
| Professional | 26 | $81.28 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $602.56 / $933.25
| Professional | | $389.05 | $602.56 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $257.04
| Professional | 26 | $123.03 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $436.52 / $676.08
| Professional | TC | $269.15 | $436.52 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $239.88 / $398.11
| Professional | | $114.82 | $239.88 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $660.69 / $1,513.56
| Professional | | $316.23 | $660.69 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $281.84
| Professional | 26 | $95.50 | $154.88 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $457.09 / $1,230.27
| Professional | TC | $218.78 | $457.09 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $501.19 / $1,258.93
| Professional | | $316.23 | $501.19 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $257.04
| Professional | 26 | $97.72 | $128.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $331.13 / $1,000.00
| Professional | TC | $218.78 | $331.13 | $1,000.00 |