- 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
- $309.03 / $426.58 / $1,023.29
| Professional | | $309.03 | $426.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $602.56
| Professional | 26 | $102.33 | $199.53 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $269.15 / $630.96
| Professional | TC | $208.93 | $269.15 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $575.44 / $645.65
| Professional | | $323.59 | $575.44 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $776.25 / $977.24
| Professional | | $616.60 | $776.25 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $251.19 / $316.23
| Professional | 26 | $199.53 | $251.19 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $416.87 / $524.81 / $660.69
| Professional | TC | $416.87 | $524.81 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $616.60 / $6,165.95
| Professional | | $316.23 | $616.60 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $323.59
| Professional | 26 | $114.82 | $194.98 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $457.09 / $5,495.41
| Professional | TC | $269.15 | $457.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $691.83 / $831.76
| Professional | | $645.65 | $691.83 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $218.78 / $229.09 / $263.03
| Professional | 26 | $218.78 | $229.09 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $426.58 / $457.09 / $562.34
| Professional | TC | $426.58 | $457.09 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Professional | 26 | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Professional | TC | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $630.96 / $1,000.00
| Professional | | $416.87 | $630.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $186.21 / $208.93
| Professional | 26 | $134.90 | $186.21 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $416.87 / $831.76
| Professional | TC | $281.84 | $416.87 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $676.08 / $954.99
| Professional | | $398.11 | $676.08 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $194.98 / $288.40
| Professional | 26 | $100.00 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $478.63 / $660.69
| Professional | TC | $218.78 | $478.63 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $851.14 / $851.14
| Professional | | $724.44 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $281.84 / $281.84
| Professional | 26 | $239.88 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $478.63 / $562.34 / $562.34
| Professional | TC | $478.63 | $562.34 | $562.34 |