- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $3,548.13
| Facility | 26 | $109.65 | $125.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $478.63 / $1,288.25
| Professional | | $331.13 | $478.63 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $371.54
| Professional | 26 | $102.33 | $165.96 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Professional | 52 | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $281.84 / $588.84
| Professional | TC | $218.78 | $281.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $660.69 / $1,288.25
| Professional | | $309.03 | $660.69 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $134.90 / $223.87
| Professional | 26 | $77.62 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $512.86 / $1,122.02
| Professional | TC | $213.80 | $512.86 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $331.13 / $398.11
| Professional | | $323.59 | $331.13 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $109.65 / $1,148.15
| Professional | 26 | $104.71 | $109.65 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $457.09 / $1,659.59
| Professional | | $79.43 | $457.09 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $134.90 / $549.54
| Professional | 26 | $79.43 | $134.90 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $346.74 / $1,122.02
| Professional | TC | $79.43 | $346.74 | $1,122.02 |