- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | 26 | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $100.00 / $213.80
| Professional | | $77.62 | $100.00 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $52.48 / $123.03
| Professional | 26 | $40.74 | $52.48 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $47.86 / $112.20
| Professional | TC | $34.67 | $47.86 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $131.83 / $177.83
| Professional | | $95.50 | $131.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $69.18 / $83.18
| Professional | 26 | $50.12 | $69.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $61.66 / $72.44
| Professional | TC | $44.67 | $61.66 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $229.09
| Professional | | $114.82 | $173.78 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $67.61 / $123.03
| Professional | 26 | $58.88 | $67.61 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $83.18 / $141.25
| Professional | TC | $53.70 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $269.15
| Professional | | $117.49 | $138.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $74.13 / $144.54
| Professional | 26 | $61.66 | $74.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $128.82
| Professional | TC | $56.23 | $67.61 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $269.15
| Professional | | $95.50 | $114.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $57.54 / $123.03
| Professional | 26 | $40.74 | $57.54 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $57.54 / $112.20
| Professional | TC | $45.71 | $57.54 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $269.15
| Professional | | $114.82 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $72.44 / $131.83
| Professional | 26 | $56.23 | $72.44 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $128.82
| Professional | TC | $53.70 | $67.61 | $128.82 |