- 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
- $338.84 / $407.38 / $2,137.96
| Professional | | $338.84 | $407.38 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $338.84
| Professional | 26 | $97.72 | $123.03 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $269.15 / $691.83
| Professional | TC | $218.78 | $269.15 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $467.74 / $645.65
| Professional | | $302.00 | $467.74 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $204.17
| Professional | 26 | $100.00 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $331.13 / $457.09
| Professional | TC | $190.55 | $331.13 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $346.74 / $575.44
| Professional | | $263.03 | $346.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $173.78
| Professional | 26 | $91.20 | $117.49 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $245.47 / $426.58
| Professional | TC | $173.78 | $245.47 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6.31 / $302.00 / $562.34
| Professional | | $6.31 | $302.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $1.62 / $100.00 / $177.83
| Professional | 26 | $1.62 | $100.00 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $4.68 / $239.88 / $398.11
| Professional | TC | $4.68 | $239.88 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.37 / $5.37 / $489.78
| Professional | | $5.37 | $5.37 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $1.38 / $1.38 / $158.49
| Professional | 26 | $1.38 | $1.38 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $3.98 / $338.84 / $354.81
| Professional | TC | $3.98 | $338.84 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $354.81
| Professional | | $331.13 | $331.13 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $112.20
| Professional | 26 | $100.00 | $104.71 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $245.47
| Professional | TC | $223.87 | $223.87 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $380.19 / $691.83
| Professional | | $42.66 | $380.19 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $141.25 / $199.53
| Professional | 26 | $104.71 | $141.25 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $446.68
| Professional | TC | $208.93 | $251.19 | $446.68 |