- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $602.56 / $1,348.96
| Professional | | $371.54 | $602.56 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $316.23
| Professional | 26 | $109.65 | $165.96 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $436.52 / $912.01
| Professional | TC | $263.03 | $436.52 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $691.83 / $1,778.28
| Professional | | $457.09 | $691.83 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $154.88 / $354.81
| Professional | 26 | $104.71 | $154.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $354.81 / $537.03 / $1,380.38
| Professional | TC | $354.81 | $537.03 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,096.48 / $1,584.89
| Professional | | $660.69 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $316.23
| Professional | 26 | $107.15 | $154.88 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $512.86 / $851.14 / $1,258.93
| Professional | TC | $512.86 | $851.14 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $707.95 / $1,348.96
| Professional | | $562.34 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $295.12
| Professional | 26 | $125.89 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $436.52 / $549.54 / $1,047.13
| Professional | TC | $436.52 | $549.54 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $630.96 / $1,348.96
| Professional | | $371.54 | $630.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $275.42
| Professional | 26 | $112.20 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $478.63 / $1,047.13
| Professional | TC | $263.03 | $478.63 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $776.25 / $1,778.28
| Professional | | $478.63 | $776.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $436.52
| Professional | 26 | $112.20 | $162.18 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $436.52 / $616.60 / $1,148.15
| Professional | TC | $436.52 | $616.60 | $1,148.15 |