- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $309.03 / $478.63
| Professional | | $263.03 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $165.96
| Professional | 26 | $91.20 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $199.53 / $309.03
| Professional | TC | $158.49 | $199.53 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $323.59 / $602.56
| Professional | | $263.03 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $190.55
| Professional | 26 | $93.33 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $208.93 / $371.54
| Professional | TC | $165.96 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $398.11 / $660.69
| Professional | | $190.55 | $398.11 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $223.87
| Professional | 26 | $114.82 | $141.25 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $245.47 / $436.52
| Professional | TC | $74.13 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $457.09 / $891.25
| Professional | | $323.59 | $457.09 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $288.40
| Professional | 26 | $107.15 | $147.91 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $302.00 / $602.56
| Professional | TC | $218.78 | $302.00 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $323.59 / $537.03
| Professional | | $269.15 | $323.59 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $107.15 / $165.96
| Professional | 26 | $93.33 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $199.53 / $371.54
| Professional | TC | $158.49 | $199.53 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $426.58 / $676.08
| Professional | | $263.03 | $426.58 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $229.09
| Professional | 26 | $104.71 | $147.91 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $281.84 / $457.09
| Professional | TC | $154.88 | $281.84 | $457.09 |