- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $478.63 / $870.96
| Professional | | $309.03 | $478.63 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $128.82 / $218.78
| Professional | 26 | $79.43 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $338.84 / $660.69
| Professional | TC | $218.78 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | 26 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $354.81 / $416.87
| Professional | | $128.82 | $354.81 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $85.11 / $109.65
| Professional | 26 | $60.26 | $85.11 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $269.15 / $316.23
| Professional | TC | $97.72 | $269.15 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $537.03 / $1,000.00
| Professional | | $323.59 | $537.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $123.03 / $208.93
| Professional | 26 | $69.18 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $426.58 / $776.25
| Professional | TC | $245.47 | $426.58 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $389.05 / $831.76
| Professional | | $275.42 | $389.05 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $134.90
| Professional | 26 | $66.07 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $288.40 / $724.44
| Professional | TC | $208.93 | $288.40 | $724.44 |