- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | 26 | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $501.19 / $1,230.27
| Professional | | $208.93 | $501.19 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $114.82 / $323.59
| Professional | 26 | $67.61 | $114.82 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $128.82 / $1,230.27 / $1,230.27
| Professional | 52 | $128.82 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $562.34
| Professional | TC | $144.54 | $316.23 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $309.03 / $309.03
| Professional | | $109.65 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $371.54 / $691.83
| Professional | | $288.40 | $371.54 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $109.65 / $194.98
| Professional | 26 | $48.98 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $302.00 / $501.19
| Professional | TC | $131.83 | $302.00 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $346.74 / $707.95
| Professional | | $338.84 | $346.74 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $446.68 / $549.54
| Professional | | $295.12 | $446.68 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $158.49
| Professional | 26 | $72.44 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $208.93 / $467.74
| Professional | TC | $138.04 | $208.93 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $354.81 / $691.83
| Professional | | $186.21 | $354.81 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $74.13 / $162.18
| Professional | 26 | $64.57 | $74.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $229.09 / $512.86
| Professional | TC | $123.03 | $229.09 | $512.86 |