- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $239.88 / $977.24
| Professional | | $173.78 | $239.88 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $309.03
| Professional | 26 | $64.57 | $91.20 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $141.25 / $275.42
| Professional | TC | $109.65 | $141.25 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $407.38
| Professional | | $204.17 | $281.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $158.49
| Professional | 26 | $83.18 | $102.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $177.83 / $245.47
| Professional | TC | $131.83 | $177.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $190.55
| Professional | | $32.36 | $33.11 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Facility | 26 | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $389.05 / $602.56
| Professional | | $275.42 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $630.96
| Professional | 26 | $97.72 | $141.25 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $416.87
| Professional | TC | $173.78 | $251.19 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $281.84 / $380.19
| Professional | | $177.83 | $281.84 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $107.15 / $147.91
| Professional | 26 | $66.07 | $107.15 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $173.78 / $208.93
| Professional | TC | $109.65 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $154.88 / $288.40
| Professional | | $87.10 | $154.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $229.09 / $371.54
| Professional | | $162.18 | $229.09 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $128.82
| Professional | 26 | $60.26 | $79.43 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $144.54 / $234.42
| Professional | TC | $107.15 | $144.54 | $234.42 |