- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $309.03 / $676.08
| Professional | | $204.17 | $309.03 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $67.61 / $107.15
| Professional | 26 | $37.15 | $67.61 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $257.04 / $602.56
| Professional | TC | $173.78 | $257.04 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $812.83
| Professional | | $478.63 | $478.63 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $131.83
| Professional | 26 | $109.65 | $109.65 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $676.08
| Professional | TC | $363.08 | $363.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $676.08 / $870.96
| Professional | | $263.03 | $676.08 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $93.33 / $131.83
| Professional | 26 | $37.15 | $93.33 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $575.44 / $741.31
| Professional | TC | $223.87 | $575.44 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $2,398.83
| Professional | | $1,096.48 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $151.36 / $323.59
| Professional | 26 | $138.04 | $151.36 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $870.96 / $933.25 / $2,089.30
| Professional | TC | $870.96 | $933.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $478.63 / $812.83
| Professional | | $263.03 | $478.63 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $50.12 / $131.83
| Professional | 26 | $35.48 | $50.12 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $323.59 / $676.08
| Professional | TC | $223.87 | $323.59 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $977.24 / $3,715.35
| Professional | | $263.03 | $977.24 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $158.49 / $602.56
| Professional | 26 | $46.77 | $158.49 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $812.83 / $3,162.28
| Professional | TC | $213.80 | $812.83 | $3,162.28 |