- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $446.68 / $912.01
| Professional | | $269.15 | $446.68 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $131.83 / $263.03
| Professional | 26 | $70.79 | $131.83 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $323.59 / $602.56
| Professional | TC | $199.53 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Professional | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $478.63 / $616.60
| Professional | | $169.82 | $478.63 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $169.82
| Professional | 26 | $91.20 | $131.83 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $354.81 / $416.87
| Professional | TC | $128.82 | $354.81 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $436.52 / $812.83
| Professional | | $251.19 | $436.52 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $181.97
| Professional | 26 | $63.10 | $104.71 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $331.13 / $645.65
| Professional | TC | $194.98 | $331.13 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $338.84 / $660.69
| Professional | | $229.09 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $75.86 / $141.25
| Professional | 26 | $57.54 | $75.86 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $562.34
| Professional | TC | $177.83 | $251.19 | $562.34 |