- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | 26 | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $478.63 / $1,230.27
| Professional | | $213.80 | $478.63 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $117.49 / $288.40
| Professional | 26 | $66.07 | $117.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Professional | 52 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $302.00 / $562.34
| Professional | TC | $141.25 | $302.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $316.23 / $316.23
| Professional | | $109.65 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $457.09 / $758.58
| Professional | | $302.00 | $457.09 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $109.65 / $194.98
| Professional | 26 | $48.98 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $346.74 / $512.86
| Professional | TC | $138.04 | $346.74 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $354.81 / $758.58
| Professional | | $346.74 | $354.81 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $457.09 / $562.34
| Professional | | $302.00 | $457.09 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $158.49
| Professional | 26 | $72.44 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $218.78 / $446.68
| Professional | TC | $141.25 | $218.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $354.81 / $645.65
| Professional | | $190.55 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $147.91
| Professional | 26 | $64.57 | $64.57 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $239.88 / $524.81
| Professional | TC | $128.82 | $239.88 | $524.81 |