- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $288.40 / $645.65
| Facility | 26 | $117.49 | $288.40 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $426.58 / $1,412.54
| Professional | | $213.80 | $426.58 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $218.78 / $457.09
| Professional | 26 | $104.71 | $218.78 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $380.19 / $912.01
| Professional | TC | $281.84 | $380.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $575.44 / $3,801.89
| Professional | | $389.05 | $575.44 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $141.25
| Professional | 26 | $112.20 | $125.89 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $389.05 / $436.52 / $501.19
| Professional | TC | $389.05 | $436.52 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $870.96 / $1,584.89
| Professional | | $389.05 | $870.96 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $288.40
| Professional | 26 | $79.43 | $120.23 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $676.08 / $1,202.26
| Professional | TC | $302.00 | $676.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $436.52 / $954.99
| Professional | | $371.54 | $436.52 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $223.87
| Professional | 26 | $91.20 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $331.13 / $758.58
| Professional | TC | $281.84 | $331.13 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $549.54 / $3,388.44
| Professional | | $95.50 | $549.54 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $177.83 / $630.96
| Professional | 26 | $95.50 | $177.83 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $512.86 / $1,905.46
| Professional | TC | $295.12 | $512.86 | $1,905.46 |