- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | 26 | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,023.29 / $3,311.31
| Professional | | $691.83 | $1,023.29 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $199.53 / $630.96
| Professional | 26 | $107.15 | $199.53 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $630.96 / $891.25 / $1,479.11
| Professional | 52 | $630.96 | $891.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $295.12 / $426.58 / $549.54
| Professional | 53 | $295.12 | $426.58 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $575.44 / $741.31 / $1,479.11
| Professional | TC | $575.44 | $741.31 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $114.82
| Professional | 26 | $83.18 | $83.18 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $758.58 / $3,090.30
| Professional | | $630.96 | $758.58 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $489.78
| Professional | 26 | $100.00 | $120.23 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $537.03 / $630.96 / $2,570.40
| Professional | TC | $537.03 | $630.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $125.89 / $177.83
| Facility | 26 | $26.92 | $125.89 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- 53
- Typical Low / Median / Typical High
- $36.31 / $181.97 / $213.80
| Facility | 53 | $36.31 | $181.97 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,023.29 / $2,041.74
| Professional | | $707.95 | $1,023.29 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $331.13
| Professional | 26 | $109.65 | $181.97 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $602.56 / $831.76 / $1,698.24
| Professional | TC | $602.56 | $831.76 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $257.04 / $794.33 / $794.33
| Facility | 26 | $257.04 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- 53
- Typical Low / Median / Typical High
- $281.84 / $645.65 / $645.65
| Facility | 53 | $281.84 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,122.02 / $5,370.32
| Professional | | $794.33 | $1,122.02 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $204.17 / $1,047.13
| Professional | 26 | $131.83 | $204.17 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $630.96 / $933.25 / $4,466.84
| Professional | TC | $630.96 | $933.25 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $954.99 / $1,621.81
| Professional | | $741.31 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $288.40
| Professional | 26 | $117.49 | $181.97 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $616.60 / $794.33 / $1,348.96
| Professional | TC | $616.60 | $794.33 | $1,348.96 |