- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | 26 | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $549.54
| Professional | | $177.83 | $263.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $107.15 / $275.42
| Professional | 26 | $61.66 | $107.15 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $338.84
| Professional | TC | $112.20 | $162.18 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | 26 | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $234.42 / $281.84
| Professional | | $87.10 | $234.42 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $79.43 / $100.00
| Professional | 26 | $54.95 | $79.43 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $158.49 / $186.21
| Professional | TC | $57.54 | $158.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $354.81 / $562.34
| Professional | | $218.78 | $354.81 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $100.00 / $194.98
| Professional | 26 | $63.10 | $100.00 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $204.17 / $371.54
| Professional | TC | $125.89 | $204.17 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $281.84 / $1,202.26
| Professional | | $186.21 | $281.84 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $81.28 / $154.88
| Professional | 26 | $61.66 | $81.28 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $190.55 / $1,023.29
| Professional | TC | $134.90 | $190.55 | $1,023.29 |