- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $457.09 / $1,023.29
| Professional | | $316.23 | $457.09 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $154.88 / $562.34
| Professional | 26 | $97.72 | $154.88 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $346.74 / $3,548.13
| Professional | TC | $229.09 | $346.74 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $616.60 / $891.25
| Professional | | $346.74 | $616.60 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $831.76 / $1,023.29
| Professional | | $660.69 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $194.98 / $239.88 / $302.00
| Professional | 26 | $194.98 | $239.88 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $467.74 / $575.44 / $724.44
| Professional | TC | $467.74 | $575.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $724.44 / $6,025.60
| Professional | | $338.84 | $724.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $190.55 / $389.05
| Professional | 26 | $112.20 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $588.84 / $5,495.41
| Professional | TC | $338.84 | $588.84 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $724.44 / $891.25
| Professional | | $676.08 | $724.44 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $257.04
| Professional | 26 | $208.93 | $223.87 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $467.74 / $512.86 / $630.96
| Professional | TC | $467.74 | $512.86 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Professional | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Professional | TC | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $660.69 / $1,023.29
| Professional | | $457.09 | $660.69 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $177.83 / $208.93
| Professional | 26 | $128.82 | $177.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $467.74 / $870.96
| Professional | TC | $323.59 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $758.58 / $1,122.02
| Professional | | $416.87 | $758.58 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $190.55 / $281.84
| Professional | 26 | $95.50 | $190.55 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $549.54 / $891.25
| Professional | TC | $295.12 | $549.54 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $891.25 / $891.25
| Professional | | $758.58 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $275.42 / $275.42
| Professional | 26 | $229.09 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $537.03 / $630.96 / $630.96
| Professional | TC | $537.03 | $630.96 | $630.96 |