- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $102.33 / $102.33
| Facility | 26 | $93.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $302.00 / $478.63
| Professional | | $169.82 | $302.00 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $93.33 / $316.23
| Professional | 26 | $75.86 | $93.33 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $213.80 / $346.74
| Professional | TC | $162.18 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $102.33 / $144.54
| Facility | 26 | $21.88 | $102.33 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $630.96 / $1,698.24
| Professional | | $269.15 | $630.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $128.82 / $457.09
| Professional | 26 | $70.79 | $128.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $478.63 / $1,380.38
| Professional | TC | $194.98 | $478.63 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $239.88 / $478.63
| Professional | 26 | $138.04 | $239.88 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Professional | TC | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $489.78 / $870.96
| Professional | | $229.09 | $489.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $104.71 / $186.21
| Professional | 26 | $56.23 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $398.11 / $691.83
| Professional | TC | $177.83 | $398.11 | $691.83 |