- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Facility | 26 | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $602.56 / $1,949.84
| Professional | | $371.54 | $602.56 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $346.74
| Professional | 26 | $87.10 | $151.36 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $457.09 / $1,548.82
| Professional | TC | $257.04 | $457.09 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,202.26 / $1,778.28
| Professional | | $691.83 | $1,202.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $208.93 / $371.54
| Professional | 26 | $91.20 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $549.54 / $1,023.29 / $1,412.54
| Professional | TC | $549.54 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Facility | 26 | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,318.26 / $3,019.95
| Professional | | $602.56 | $1,318.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $151.36 / $309.03 / $776.25
| Professional | 26 | $151.36 | $309.03 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $457.09 / $977.24 / $2,187.76
| Professional | TC | $457.09 | $977.24 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,089.30 / $3,467.37
| Professional | | $1,949.84 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $389.05 / $426.58 / $724.44
| Professional | 26 | $389.05 | $426.58 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $1,348.96 / $1,659.59 / $2,754.23
| Professional | TC | $1,348.96 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,202.26 / $1,513.56
| Professional | | $831.76 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $338.84 / $363.08
| Professional | 26 | $107.15 | $338.84 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $426.58 / $831.76 / $1,412.54
| Professional | TC | $426.58 | $831.76 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,412.54 / $3,801.89
| Professional | | $645.65 | $1,412.54 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $316.23 / $758.58
| Professional | 26 | $117.49 | $316.23 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $489.78 / $1,258.93 / $3,090.30
| Professional | TC | $489.78 | $1,258.93 | $3,090.30 |