- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | 26 | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $446.68 / $1,230.27
| Professional | | $275.42 | $446.68 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $131.83 / $275.42
| Professional | 26 | $69.18 | $131.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $288.40 / $588.84 / $812.83
| Professional | 52 | $288.40 | $588.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $316.23 / $794.33
| Professional | TC | $190.55 | $316.23 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $870.96 / $1,047.13
| Professional | | $398.11 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $165.96 / $316.23
| Professional | 26 | $70.79 | $165.96 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $616.60 / $758.58
| Professional | TC | $281.84 | $616.60 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | 26 | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $776.25 / $1,737.80
| Professional | | $478.63 | $776.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $245.47 / $616.60
| Professional | 26 | $131.83 | $245.47 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $288.40 / $588.84 / $812.83
| Professional | 52 | $288.40 | $588.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $537.03 / $1,122.02
| Professional | TC | $338.84 | $537.03 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,148.15 / $1,949.84
| Professional | | $1,122.02 | $1,148.15 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $309.03 / $338.84 / $575.44
| Professional | 26 | $309.03 | $338.84 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $707.95 / $812.83 / $1,380.38
| Professional | TC | $707.95 | $812.83 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $707.95 / $1,023.29
| Professional | | $478.63 | $707.95 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $275.42 / $316.23
| Professional | 26 | $85.11 | $275.42 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $616.60 / $1,000.00
| Professional | TC | $208.93 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $912.01 / $3,019.95
| Professional | | $363.08 | $912.01 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $251.19 / $602.56
| Professional | 26 | $95.50 | $251.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $645.65 / $2,398.83
| Professional | TC | $275.42 | $645.65 | $2,398.83 |