- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | 26 | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $426.58 / $912.01
| Professional | | $218.78 | $426.58 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $165.96 / $338.84
| Professional | 26 | $104.71 | $165.96 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $338.84 / $776.25
| Professional | TC | $257.04 | $338.84 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $489.78 / $1,258.93
| Professional | | $338.84 | $489.78 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $147.91 / $331.13
| Professional | 26 | $100.00 | $147.91 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $346.74 / $891.25
| Professional | TC | $234.42 | $346.74 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $891.25 / $1,258.93
| Professional | | $467.74 | $891.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $147.91 / $302.00
| Professional | 26 | $102.33 | $147.91 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $331.13 / $645.65 / $1,096.48
| Professional | TC | $331.13 | $645.65 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $512.86 / $954.99
| Professional | | $407.38 | $512.86 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $281.84
| Professional | 26 | $120.23 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $363.08 / $676.08
| Professional | TC | $288.40 | $363.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14,125.38 / $14,125.38 / $14,125.38
| Facility | 26 | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $562.34 / $1,096.48
| Professional | | $371.54 | $562.34 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $154.88 / $257.04
| Professional | 26 | $112.20 | $154.88 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $389.05 / $870.96
| Professional | TC | $263.03 | $389.05 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $630.96 / $1,318.26
| Professional | | $338.84 | $630.96 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $151.36 / $389.05
| Professional | 26 | $97.72 | $151.36 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $457.09 / $954.99
| Professional | TC | $239.88 | $457.09 | $954.99 |