- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $478.63 / $1,230.27
| Professional | | $371.54 | $478.63 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $275.42
| Professional | 26 | $125.89 | $151.36 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $295.12 / $467.74
| Professional | TC | $239.88 | $295.12 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $549.54 / $851.14
| Professional | | $354.81 | $549.54 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $190.55 / $295.12
| Professional | 26 | $125.89 | $190.55 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $354.81 / $549.54
| Professional | TC | $229.09 | $354.81 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $549.54 / $812.83
| Professional | | $407.38 | $549.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $186.21 / $275.42
| Professional | 26 | $158.49 | $186.21 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $371.54 / $537.03
| Professional | TC | $251.19 | $371.54 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $524.81 / $758.58
| Professional | | $416.87 | $524.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $186.21 / $257.04
| Professional | 26 | $154.88 | $186.21 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $331.13 / $512.86
| Professional | TC | $251.19 | $331.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $457.09 / $616.60
| Professional | | $371.54 | $457.09 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $223.87
| Professional | 26 | $125.89 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $309.03 / $389.05
| Professional | TC | $239.88 | $309.03 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $537.03 / $1,000.00
| Professional | | $416.87 | $537.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $190.55 / $275.42
| Professional | 26 | $154.88 | $190.55 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $346.74 / $575.44
| Professional | TC | $251.19 | $346.74 | $575.44 |