- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $32.36
| Facility | 26 | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $97.72 / $245.47
| Professional | | $74.13 | $97.72 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $33.11 / $47.86
| Professional | 26 | $28.84 | $33.11 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $64.57 / $83.18
| Professional | TC | $38.90 | $64.57 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $97.72 / $134.90
| Professional | | $33.88 | $97.72 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $93.33 / $134.90
| Professional | | $58.88 | $93.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $44.67 / $57.54
| Professional | 26 | $33.11 | $44.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $47.86 / $91.20
| Professional | TC | $19.05 | $47.86 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $151.36 / $151.36
| Facility | 26 | $77.62 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $100.00 / $691.83
| Professional | | $64.57 | $100.00 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $38.90 / $223.87
| Professional | 26 | $29.51 | $38.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $58.88 / $467.74
| Professional | TC | $26.30 | $58.88 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $87.10 / $134.90
| Professional | | $61.66 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $35.48 / $53.70
| Professional | 26 | $28.84 | $35.48 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $51.29 / $85.11
| Professional | TC | $23.44 | $51.29 | $85.11 |