- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Facility | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $169.82 / $302.00
| Professional | | $151.36 | $169.82 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $60.26 / $125.89
| Professional | 26 | $52.48 | $60.26 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $109.65 / $158.49
| Professional | TC | $95.50 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $302.00 / $457.09
| Professional | | $138.04 | $302.00 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $74.13 / $114.82
| Professional | 26 | $51.29 | $74.13 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $229.09 / $346.74
| Professional | TC | $83.18 | $229.09 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $354.81 / $630.96
| Professional | | $251.19 | $354.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $128.82
| Professional | 26 | $54.95 | $69.18 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $269.15 / $512.86
| Professional | TC | $190.55 | $269.15 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $323.59 / $501.19
| Professional | | $257.04 | $323.59 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $63.10 / $102.33
| Professional | 26 | $52.48 | $63.10 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $263.03 / $407.38
| Professional | TC | $204.17 | $263.03 | $407.38 |