- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $223.87 / $549.54
| Professional | | $107.15 | $223.87 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $74.13 / $169.82
| Professional | 26 | $26.92 | $74.13 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $120.23 / $204.17 / $338.84
| Professional | 52 | $120.23 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $104.71 / $275.42
| Professional | TC | $70.79 | $104.71 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $199.53
| Professional | | $109.65 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $40.74 / $67.61
| Professional | 26 | $28.18 | $40.74 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $144.54
| Professional | TC | $74.13 | $107.15 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $158.49 / $257.04
| Professional | | $93.33 | $158.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $47.86 / $72.44
| Professional | 26 | $30.90 | $47.86 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $123.03 / $186.21
| Professional | TC | $79.43 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $131.83 / $229.09
| Professional | | $93.33 | $131.83 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $38.90 / $91.20
| Professional | 26 | $30.20 | $38.90 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $100.00 / $165.96
| Professional | TC | $60.26 | $100.00 | $165.96 |