- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | 26 | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $407.38 / $891.25
| Professional | | $257.04 | $407.38 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $123.03 / $257.04
| Professional | 26 | $74.13 | $123.03 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $288.40 / $630.96
| Professional | TC | $181.97 | $288.40 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $478.63 / $691.83
| Professional | | $346.74 | $478.63 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $204.17
| Professional | 26 | $102.33 | $141.25 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $338.84 / $489.78
| Professional | TC | $245.47 | $338.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $489.78 / $1,047.13
| Professional | | $426.58 | $489.78 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $144.54 / $309.03
| Professional | 26 | $123.03 | $144.54 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $354.81 / $758.58
| Professional | TC | $295.12 | $354.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $691.83 / $1,096.48
| Professional | | $407.38 | $691.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $199.53 / $309.03
| Professional | 26 | $117.49 | $199.53 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $489.78 / $758.58
| Professional | TC | $288.40 | $489.78 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $457.09 / $1,258.93
| Professional | | $389.05 | $457.09 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $309.03
| Professional | 26 | $109.65 | $134.90 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $323.59 / $758.58
| Professional | TC | $275.42 | $323.59 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Facility | 26 | $75.86 | $75.86 | $75.86 |