- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $154.88 / $346.74
| Professional | | $91.20 | $154.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $46.77 / $117.49
| Professional | 26 | $32.36 | $46.77 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $95.50 / $269.15
| Professional | TC | $56.23 | $95.50 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $371.54
| Professional | | $131.83 | $186.21 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $66.07 / $147.91
| Professional | 26 | $45.71 | $66.07 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $120.23 / $229.09
| Professional | TC | $93.33 | $120.23 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $436.52 / $1,000.00
| Professional | | $162.18 | $436.52 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $123.03 / $295.12
| Professional | 26 | $53.70 | $123.03 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $323.59 / $707.95
| Professional | TC | $104.71 | $323.59 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $660.69 / $724.44
| Professional | | $338.84 | $660.69 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $165.96 / $234.42
| Professional | 26 | $154.88 | $165.96 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $478.63 / $501.19
| Professional | TC | $173.78 | $478.63 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $323.59 / $416.87
| Professional | | $123.03 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $48.98 / $147.91
| Professional | 26 | $33.11 | $48.98 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $95.50 / $229.09
| Professional | TC | $45.71 | $95.50 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $257.04 / $331.13
| Professional | | $112.20 | $257.04 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $117.49 / $123.03
| Professional | 26 | $51.29 | $117.49 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $229.09
| Professional | TC | $95.50 | $138.04 | $229.09 |