- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $32.36
| Facility | 26 | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $181.97 / $501.19
| Professional | | $112.20 | $181.97 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $57.54 / $147.91
| Professional | 26 | $30.90 | $57.54 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $275.42
| Professional | 52 | $102.33 | $102.33 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $112.20 / $213.80
| Professional | TC | $79.43 | $112.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $467.74 / $467.74
| Professional | | $302.00 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $128.82
| Professional | 26 | $83.18 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $338.84 / $338.84
| Professional | TC | $218.78 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $194.98 / $363.08
| Professional | | $102.33 | $194.98 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $57.54 / $102.33
| Professional | 26 | $33.11 | $57.54 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $128.82 / $245.47
| Professional | TC | $74.13 | $128.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $239.88 / $416.87
| Professional | | $125.89 | $239.88 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $70.79 / $123.03
| Professional | 26 | $34.67 | $70.79 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $173.78 / $295.12
| Professional | TC | $89.13 | $173.78 | $295.12 |