- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $131.83 / $323.59
| Facility | 26 | $85.11 | $131.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $426.58 / $1,122.02
| Professional | | $204.17 | $426.58 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $93.33 / $263.03
| Professional | 26 | $66.07 | $93.33 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $588.84
| Professional | 52 | $97.72 | $169.82 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $263.03 / $512.86
| Professional | TC | $128.82 | $263.03 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $199.53 / $331.13
| Professional | | $147.91 | $199.53 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $91.20 / $125.89
| Professional | 26 | $58.88 | $91.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $199.53
| Professional | TC | $169.82 | $169.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $467.74 / $794.33
| Professional | | $234.42 | $467.74 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $97.72 / $158.49
| Professional | 26 | $69.18 | $97.72 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $323.59 / $676.08
| Professional | TC | $158.49 | $323.59 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $138.04 / $245.47
| Professional | | $70.79 | $138.04 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $489.78 / $954.99
| Professional | | $199.53 | $489.78 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $107.15 / $204.17
| Professional | 26 | $63.10 | $107.15 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $331.13 / $794.33
| Professional | TC | $128.82 | $331.13 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $257.04 / $1,348.96
| Professional | | $199.53 | $257.04 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $302.00
| Professional | 26 | $69.18 | $93.33 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $251.19
| Professional | 52 | $177.83 | $177.83 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $323.59
| Professional | 53 | $177.83 | $251.19 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $1,230.27
| Professional | TC | $128.82 | $169.82 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $181.97 / $363.08
| Professional | | $72.44 | $181.97 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $371.54 / $794.33
| Professional | | $204.17 | $371.54 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $165.96
| Professional | 26 | $64.57 | $83.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $239.88 / $616.60
| Professional | TC | $131.83 | $239.88 | $616.60 |