- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $331.13
| Professional | | $87.10 | $120.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $194.98
| Professional | 26 | $57.54 | $72.44 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $42.66 / $112.20
| Professional | TC | $28.18 | $42.66 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $69.18
| Professional | 26 | $58.88 | $58.88 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $257.04 / $380.19
| Professional | | $104.71 | $257.04 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $147.91 / $213.80
| Professional | 26 | $58.88 | $147.91 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $112.20 / $162.18
| Professional | TC | $44.67 | $112.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $177.83 / $309.03
| Professional | | $125.89 | $177.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $107.15 / $173.78
| Professional | 26 | $77.62 | $107.15 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $67.61 / $134.90
| Professional | TC | $43.65 | $67.61 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $144.54 / $269.15
| Professional | | $102.33 | $144.54 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $165.96
| Professional | 26 | $64.57 | $91.20 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $67.61 / $123.03
| Professional | TC | $48.98 | $67.61 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $316.23
| Professional | | $114.82 | $169.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $107.15 / $186.21
| Professional | 26 | $64.57 | $107.15 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $123.03
| Professional | TC | $39.81 | $61.66 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $46.77 / $72.44
| Facility | 26 | $44.67 | $46.77 | $72.44 |