- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $257.04 / $316.23
| Facility | 26 | $114.82 | $257.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $380.19 / $1,445.44
| Professional | | $218.78 | $380.19 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $87.10 / $213.80
| Professional | 26 | $57.54 | $87.10 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $602.56
| Professional | TC | $158.49 | $218.78 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $645.65 / $1,000.00
| Professional | | $263.03 | $645.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $123.03 / $177.83
| Professional | 26 | $66.07 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $478.63 / $776.25
| Professional | TC | $186.21 | $478.63 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $549.54 / $870.96
| Professional | | $338.84 | $549.54 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $194.98
| Professional | 26 | $72.44 | $97.72 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $446.68 / $691.83
| Professional | TC | $275.42 | $446.68 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $512.86 / $660.69
| Professional | | $331.13 | $512.86 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $87.10 / $104.71
| Professional | 26 | $75.86 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $489.78
| Professional | TC | $245.47 | $309.03 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $575.44
| Professional | | $93.33 | $112.20 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $371.54 / $912.01
| Professional | | $239.88 | $371.54 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $85.11 / $204.17
| Professional | 26 | $58.88 | $85.11 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $281.84 / $691.83
| Professional | TC | $177.83 | $281.84 | $691.83 |