- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $61.66
| Facility | 26 | $61.66 | $61.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $371.54 / $724.44
| Professional | | $204.17 | $371.54 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $123.03 / $199.53
| Professional | 26 | $57.54 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $257.04
| Professional | TC | $144.54 | $169.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $151.36 / $331.13
| Professional | | $60.26 | $151.36 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $69.18 / $97.72
| Facility | 26 | $14.79 | $69.18 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $295.12 / $1,000.00
| Professional | | $204.17 | $295.12 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $87.10 / $309.03
| Professional | 26 | $58.88 | $87.10 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $204.17 / $724.44
| Professional | TC | $147.91 | $204.17 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Professional | TC | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $245.47 / $389.05
| Professional | | $177.83 | $245.47 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $72.44 / $114.82
| Professional | 26 | $56.23 | $72.44 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $173.78 / $281.84
| Professional | TC | $128.82 | $173.78 | $281.84 |