- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | 26 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $338.84 / $562.34
| Professional | | $204.17 | $338.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $104.71 / $177.83
| Professional | 26 | $67.61 | $104.71 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $371.54
| Professional | TC | $134.90 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $776.25
| Professional | | $218.78 | $323.59 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $245.47
| Professional | 26 | $72.44 | $109.65 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $537.03
| Professional | TC | $144.54 | $213.80 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $338.84 / $724.44
| Professional | | $263.03 | $338.84 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $213.80
| Professional | 26 | $77.62 | $104.71 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $467.74
| Professional | TC | $173.78 | $223.87 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $331.13 / $645.65
| Professional | | $263.03 | $331.13 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $112.20 / $208.93
| Professional | 26 | $89.13 | $112.20 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $218.78 / $436.52
| Professional | TC | $173.78 | $218.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $398.11 / $933.25
| Professional | | $218.78 | $398.11 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $123.03 / $208.93
| Professional | 26 | $70.79 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $257.04 / $436.52
| Professional | TC | $151.36 | $257.04 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $398.11 / $977.24
| Professional | | $223.87 | $398.11 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $117.49 / $309.03
| Professional | 26 | $79.43 | $117.49 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $275.42 / $676.08
| Professional | TC | $158.49 | $275.42 | $676.08 |