- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $1,698.24 / $1,698.24
| Facility | 26 | $63.10 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $1,659.59
| Professional | | $144.54 | $316.23 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $147.91 / $398.11
| Professional | 26 | $61.66 | $147.91 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | 52 | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $338.84 / $436.52
| Professional | TC | $138.04 | $338.84 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $812.83 / $1,548.82
| Professional | | $537.03 | $812.83 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $478.63
| Professional | 26 | $162.18 | $251.19 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $562.34 / $1,071.52
| Professional | TC | $363.08 | $562.34 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $512.86 / $1,000.00
| Professional | | $309.03 | $512.86 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $134.90 / $302.00
| Professional | 26 | $89.13 | $134.90 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $363.08 / $588.84
| Professional | TC | $218.78 | $363.08 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $478.63 / $1,479.11
| Professional | | $363.08 | $478.63 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $120.23 / $208.93
| Professional | 26 | $57.54 | $120.23 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $363.08 / $1,258.93
| Professional | TC | $257.04 | $363.08 | $1,258.93 |