- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | 26 | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,047.13 / $4,073.80
| Professional | | $758.58 | $1,047.13 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $204.17 / $549.54
| Professional | 26 | $109.65 | $204.17 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Professional | 53 | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $630.96 / $794.33 / $1,380.38
| Professional | TC | $630.96 | $794.33 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,174.90 / $1,778.28
| Professional | | $870.96 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $239.88 / $302.00
| Professional | 26 | $138.04 | $239.88 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $741.31 / $933.25 / $1,479.11
| Professional | TC | $741.31 | $933.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $1,698.24
| Professional | | $32.36 | $33.11 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | 26 | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $912.01 / $2,041.74
| Professional | | $707.95 | $912.01 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $131.83 / $467.74
| Professional | 26 | $107.15 | $131.83 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $602.56 / $776.25 / $1,584.89
| Professional | TC | $602.56 | $776.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,047.13 / $1,698.24
| Professional | | $741.31 | $1,047.13 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $281.84
| Professional | 26 | $114.82 | $169.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $630.96 / $870.96 / $1,412.54
| Professional | TC | $630.96 | $870.96 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $831.76 / $1,412.54
| Professional | | $151.36 | $831.76 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,000.00 / $1,621.81
| Professional | | $724.44 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $190.55 / $316.23
| Professional | 26 | $109.65 | $190.55 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $616.60 / $851.14 / $1,288.25
| Professional | TC | $616.60 | $851.14 | $1,288.25 |