- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $27.54 / $27.54
| Facility | 26 | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $81.28 / $123.03
| Professional | | $53.70 | $81.28 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $51.29 / $107.15
| Professional | 26 | $25.70 | $51.29 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $89.13
| Professional | 52 | $25.70 | $25.70 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $34.67 / $54.95
| Professional | TC | $22.39 | $34.67 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $208.93
| Professional | | $134.90 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $112.20 / $112.20
| Professional | 26 | $72.44 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $95.50 / $95.50
| Professional | TC | $61.66 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $158.49
| Professional | | $56.23 | $97.72 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $53.70 / $85.11
| Professional | 26 | $31.62 | $53.70 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $45.71 / $72.44
| Professional | TC | $23.99 | $45.71 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $93.33 / $173.78
| Professional | | $58.88 | $93.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $51.29 / $93.33
| Professional | 26 | $31.62 | $51.29 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $42.66 / $79.43
| Professional | TC | $26.92 | $42.66 | $79.43 |