- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $524.81 / $1,023.29
| Professional | | $398.11 | $524.81 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $204.17
| Professional | 26 | $67.61 | $87.10 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $436.52 / $851.14
| Professional | TC | $323.59 | $436.52 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $602.56 / $831.76
| Professional | | $436.52 | $602.56 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $114.82 / $138.04
| Professional | 26 | $81.28 | $114.82 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $489.78 / $588.84
| Professional | TC | $363.08 | $489.78 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $616.60 / $1,148.15
| Professional | | $562.34 | $616.60 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $112.20 / $204.17
| Professional | 26 | $97.72 | $112.20 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $457.09 / $501.19 / $933.25
| Professional | TC | $457.09 | $501.19 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $660.69 / $1,258.93
| Professional | | $549.54 | $660.69 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $123.03 / $234.42
| Professional | 26 | $102.33 | $123.03 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $446.68 / $537.03 / $1,047.13
| Professional | TC | $446.68 | $537.03 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $537.03 / $1,174.90
| Professional | | $426.58 | $537.03 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $95.50 / $194.98
| Professional | 26 | $69.18 | $95.50 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $371.54 / $467.74 / $977.24
| Professional | TC | $371.54 | $467.74 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $691.83 / $1,258.93
| Professional | | $549.54 | $691.83 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $218.78
| Professional | 26 | $93.33 | $117.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $446.68 / $588.84 / $1,023.29
| Professional | TC | $446.68 | $588.84 | $1,023.29 |