- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | 26 | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $933.25 / $1,949.84
| Professional | | $691.83 | $933.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $177.83 / $436.52
| Professional | 26 | $107.15 | $177.83 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $275.42 / $891.25 / $1,000.00
| Professional | 52 | $275.42 | $891.25 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Professional | 53 | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $562.34 / $741.31 / $1,380.38
| Professional | TC | $562.34 | $741.31 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $134.90 / $154.88
| Professional | 26 | $117.49 | $134.90 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $851.14 / $1,096.48
| Professional | | $602.56 | $851.14 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $165.96
| Professional | 26 | $91.20 | $131.83 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $512.86 / $724.44 / $933.25
| Professional | TC | $512.86 | $724.44 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,000.00 / $2,398.83
| Professional | | $691.83 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $371.54
| Professional | 26 | $114.82 | $194.98 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $549.54 / $794.33 / $1,949.84
| Professional | TC | $549.54 | $794.33 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $870.96 / $1,318.26
| Professional | | $660.69 | $870.96 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $245.47
| Professional | 26 | $104.71 | $151.36 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $549.54 / $724.44 / $1,047.13
| Professional | TC | $549.54 | $724.44 | $1,047.13 |