- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | 26 | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $426.58 / $691.83
| Professional | | $354.81 | $426.58 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $61.66 / $97.72
| Professional | 26 | $50.12 | $61.66 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $371.54 / $602.56
| Professional | TC | $295.12 | $371.54 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $676.08 / $1,071.52
| Professional | | $446.68 | $676.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $89.13 / $147.91
| Professional | 26 | $58.88 | $89.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $380.19 / $562.34 / $912.01
| Professional | TC | $380.19 | $562.34 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $707.95 / $1,258.93
| Professional | | $489.78 | $707.95 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $104.71 / $190.55
| Professional | 26 | $66.07 | $104.71 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $426.58 / $602.56 / $1,096.48
| Professional | TC | $426.58 | $602.56 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $724.44 / $1,174.90
| Professional | | $489.78 | $724.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $97.72 / $154.88
| Professional | 26 | $64.57 | $97.72 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $426.58 / $616.60 / $1,000.00
| Professional | TC | $426.58 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $776.25 / $1,412.54
| Professional | | $489.78 | $776.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $107.15 / $173.78
| Professional | 26 | $64.57 | $107.15 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $426.58 / $645.65 / $1,071.52
| Professional | TC | $426.58 | $645.65 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $42.66 / $93.33
| Facility | 26 | $36.31 | $42.66 | $93.33 |