- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $165.96 / $165.96
| Facility | 26 | $100.00 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $524.81 / $1,659.59
| Professional | | $281.84 | $524.81 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $218.78 / $436.52
| Professional | 26 | $104.71 | $218.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $338.84 / $758.58
| Professional | TC | $204.17 | $338.84 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $229.09 / $489.78
| Professional | | $112.20 | $229.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $138.04
| Professional | 26 | $79.43 | $120.23 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $707.95 / $831.76
| Professional | | $257.04 | $707.95 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $223.87 / $288.40
| Professional | 26 | $158.49 | $223.87 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $478.63 / $562.34
| Professional | TC | $173.78 | $478.63 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $562.34 / $1,122.02
| Professional | | $309.03 | $562.34 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $165.96 / $288.40
| Professional | 26 | $104.71 | $165.96 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $398.11 / $954.99
| Professional | TC | $208.93 | $398.11 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $407.38 / $1,258.93
| Professional | | $275.42 | $407.38 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $234.42
| Professional | 26 | $87.10 | $117.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $275.42 / $1,023.29
| Professional | TC | $190.55 | $275.42 | $1,023.29 |