- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Facility | 26 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $194.98 / $426.58
| Professional | | $144.54 | $194.98 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $64.57 / $151.36
| Professional | 26 | $44.67 | $64.57 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $131.83 / $295.12
| Professional | TC | $93.33 | $131.83 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $218.78 / $489.78
| Professional | | $147.91 | $218.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $75.86 / $173.78
| Professional | 26 | $52.48 | $75.86 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $316.23
| Professional | TC | $95.50 | $141.25 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $302.00 / $575.44
| Professional | | $194.98 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $79.43 / $158.49
| Professional | 26 | $54.95 | $79.43 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $218.78 / $398.11
| Professional | TC | $125.89 | $218.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $426.58
| Professional | | $177.83 | $223.87 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $79.43 / $147.91
| Professional | 26 | $63.10 | $79.43 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $147.91 / $275.42
| Professional | TC | $117.49 | $147.91 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | 26 | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $251.19 / $512.86
| Professional | | $158.49 | $251.19 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $72.44 / $134.90
| Professional | 26 | $51.29 | $72.44 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $346.74
| Professional | TC | $107.15 | $169.82 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $446.68
| Professional | | $154.88 | $229.09 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $81.28 / $218.78
| Professional | 26 | $56.23 | $81.28 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $295.12
| Professional | TC | $104.71 | $144.54 | $295.12 |