- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $446.68 / $1,071.52
| Professional | | $275.42 | $446.68 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $107.15 / $223.87
| Professional | 26 | $63.10 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $338.84 / $891.25
| Professional | TC | $204.17 | $338.84 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $891.25 / $1,258.93
| Professional | | $501.19 | $891.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $134.90 / $269.15
| Professional | 26 | $58.88 | $134.90 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $407.38 / $630.96 / $1,023.29
| Professional | TC | $407.38 | $630.96 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $891.25 / $2,137.96
| Professional | | $489.78 | $891.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $204.17 / $501.19
| Professional | 26 | $123.03 | $204.17 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $371.54 / $707.95 / $1,621.81
| Professional | TC | $371.54 | $707.95 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,479.11 / $2,454.71
| Professional | | $1,412.54 | $1,479.11 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $251.19 / $275.42 / $467.74
| Professional | 26 | $251.19 | $275.42 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $1,000.00 / $1,202.26 / $2,041.74
| Professional | TC | $1,000.00 | $1,202.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $870.96 / $1,096.48
| Professional | | $575.44 | $870.96 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $223.87 / $269.15
| Professional | 26 | $69.18 | $223.87 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $630.96 / $1,023.29
| Professional | TC | $309.03 | $630.96 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $933.25 / $2,754.23
| Professional | | $416.87 | $933.25 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $204.17 / $549.54
| Professional | 26 | $89.13 | $204.17 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $331.13 / $741.31 / $2,238.72
| Professional | TC | $331.13 | $741.31 | $2,238.72 |