- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | 26 | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $371.54 / $831.76
| Professional | | $275.42 | $371.54 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $281.84
| Professional | 26 | $95.50 | $138.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $245.47 / $426.58
| Professional | TC | $169.82 | $245.47 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $457.09 / $1,071.52
| Professional | | $316.23 | $457.09 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $363.08
| Professional | 26 | $109.65 | $162.18 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $281.84 / $724.44
| Professional | TC | $199.53 | $281.84 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $645.65 / $1,000.00
| Professional | | $436.52 | $645.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $251.19
| Professional | 26 | $114.82 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $457.09 / $676.08
| Professional | TC | $275.42 | $457.09 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $501.19 / $933.25
| Professional | | $389.05 | $501.19 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $316.23
| Professional | 26 | $134.90 | $169.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $331.13 / $616.60
| Professional | TC | $257.04 | $331.13 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $141.25
| Facility | 26 | $134.90 | $134.90 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $407.38 / $812.83
| Professional | | $302.00 | $407.38 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $263.03
| Professional | 26 | $104.71 | $144.54 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $275.42 / $501.19
| Professional | TC | $186.21 | $275.42 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $575.44 / $954.99
| Professional | | $338.84 | $575.44 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $467.74
| Professional | 26 | $117.49 | $169.82 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $398.11 / $691.83
| Professional | TC | $223.87 | $398.11 | $691.83 |