- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $281.84 / $4,466.84
| Facility | 26 | $123.03 | $281.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $630.96 / $1,202.26
| Professional | | $489.78 | $630.96 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $416.87
| Professional | 26 | $102.33 | $165.96 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $245.47 / $269.15 / $275.42
| Professional | 52 | $245.47 | $269.15 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $398.11 / $501.19 / $977.24
| Professional | TC | $398.11 | $501.19 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $851.14 / $1,318.26
| Professional | | $549.54 | $851.14 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $177.83 / $263.03
| Professional | 26 | $100.00 | $177.83 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $446.68 / $676.08 / $1,023.29
| Professional | TC | $446.68 | $676.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | 26 | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $870.96 / $1,380.38
| Professional | | $524.81 | $870.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $158.49 / $275.42
| Professional | 26 | $97.72 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $416.87 / $676.08 / $1,122.02
| Professional | TC | $416.87 | $676.08 | $1,122.02 |