- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $47.86 / $117.49
| Facility | 26 | $34.67 | $47.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $371.54
| Professional | | $95.50 | $128.82 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $58.88 / $128.82
| Professional | 26 | $32.36 | $58.88 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $85.11 / $194.98
| Professional | TC | $63.10 | $85.11 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $95.50
| Professional | 26 | $39.81 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $79.43 / $104.71
| Professional | 26 | $54.95 | $79.43 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $131.83 / $229.09
| Professional | TC | $93.33 | $131.83 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $302.00
| Professional | | $97.72 | $162.18 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $53.70 / $97.72
| Professional | 26 | $31.62 | $53.70 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $204.17
| Professional | TC | $63.10 | $109.65 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | 26 | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $114.82 / $245.47
| Professional | | $39.81 | $114.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $275.42
| Professional | | $95.50 | $138.04 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $45.71 / $93.33
| Professional | 26 | $33.11 | $45.71 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $177.83
| Professional | TC | $64.57 | $91.20 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | 26 | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,000.00
| Professional | | $812.83 | $812.83 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $309.03
| Professional | 26 | $239.88 | $239.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $707.95
| Professional | TC | $575.44 | $575.44 | $707.95 |