- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | 26 | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $371.54 / $851.14
| Professional | | $316.23 | $371.54 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $107.15 / $263.03
| Professional | 26 | $97.72 | $107.15 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $269.15 / $602.56
| Professional | TC | $218.78 | $269.15 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $457.09 / $1,071.52
| Professional | | $323.59 | $457.09 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $138.04 / $371.54
| Professional | 26 | $120.23 | $138.04 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $691.83
| Professional | TC | $204.17 | $288.40 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | 26 | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,071.52 / $2,290.87
| Professional | | $512.86 | $1,071.52 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $338.84 / $758.58
| Professional | 26 | $144.54 | $338.84 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $724.44 / $1,513.56
| Professional | TC | $363.08 | $724.44 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,949.84
| Professional | | $1,479.11 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $660.69
| Professional | 26 | $426.58 | $426.58 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $954.99 / $1,071.52 / $1,318.26
| Professional | TC | $954.99 | $1,071.52 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $812.83 / $812.83
| Professional | | $309.03 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $144.54 / $371.54
| Professional | 26 | $102.33 | $144.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $302.00 / $691.83
| Professional | TC | $208.93 | $302.00 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $851.14 / $1,778.28
| Professional | | $354.81 | $851.14 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $302.00 / $691.83
| Professional | 26 | $112.20 | $302.00 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $549.54 / $1,071.52
| Professional | TC | $245.47 | $549.54 | $1,071.52 |