- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Facility | 26 | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $398.11 / $2,754.23
| Professional | | $309.03 | $398.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $177.83 / $245.47
| Professional | 26 | $81.28 | $177.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $302.00 / $446.68
| Professional | TC | $223.87 | $302.00 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $1,584.89
| Professional | | $380.19 | $380.19 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $363.08
| Professional | 26 | $91.20 | $91.20 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $338.84
| Professional | TC | $288.40 | $288.40 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $467.74 / $1,096.48
| Professional | | $416.87 | $467.74 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $269.15
| Professional | 26 | $112.20 | $125.89 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $331.13 / $691.83
| Professional | TC | $186.21 | $331.13 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | 26 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Professional | TC | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $446.68 / $1,071.52
| Professional | | $316.23 | $446.68 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $229.09
| Professional | 26 | $85.11 | $109.65 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $302.00 / $616.60
| Professional | TC | $229.09 | $302.00 | $616.60 |