- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | 26 | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $489.78 / $1,230.27
| Professional | | $199.53 | $489.78 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $117.49 / $263.03
| Professional | 26 | $67.61 | $117.49 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Professional | 52 | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $338.84 / $812.83
| Professional | TC | $154.88 | $338.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $281.84 / $524.81
| Professional | | $194.98 | $281.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $91.20 / $158.49
| Professional | 26 | $70.79 | $91.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $169.82 / $213.80
| Professional | TC | $125.89 | $169.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $426.58 / $707.95
| Professional | | $208.93 | $426.58 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $131.83 / $154.88
| Professional | 26 | $64.57 | $131.83 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $281.84 / $602.56
| Professional | TC | $138.04 | $281.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $316.23 / $602.56
| Professional | | $218.78 | $316.23 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $112.20
| Professional | 26 | $69.18 | $83.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $190.55 / $416.87
| Professional | TC | $134.90 | $190.55 | $416.87 |