- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | 26 | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $537.03 / $1,174.90
| Professional | | $380.19 | $537.03 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $275.42 / $562.34
| Professional | 26 | $162.18 | $275.42 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $281.84 / $602.56
| Professional | TC | $190.55 | $281.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $181.97 / $309.03 / $741.31
| Professional | 26 | $181.97 | $309.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $660.69 / $954.99
| Professional | | $478.63 | $660.69 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $316.23 / $457.09
| Professional | 26 | $223.87 | $316.23 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $338.84 / $501.19
| Professional | TC | $251.19 | $338.84 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $676.08 / $1,412.54
| Professional | | $588.84 | $676.08 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $269.15 / $316.23 / $676.08
| Professional | 26 | $269.15 | $316.23 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $316.23 / $363.08 / $758.58
| Professional | TC | $316.23 | $363.08 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $933.25 / $1,479.11
| Professional | | $549.54 | $933.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $263.03 / $446.68 / $676.08
| Professional | 26 | $263.03 | $446.68 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $501.19 / $758.58
| Professional | TC | $295.12 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $660.69 / $1,513.56
| Professional | | $524.81 | $660.69 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $245.47 / $302.00 / $691.83
| Professional | 26 | $245.47 | $302.00 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $346.74 / $794.33
| Professional | TC | $275.42 | $346.74 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | 26 | $169.82 | $169.82 | $169.82 |