- 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
- $575.44 / $691.83 / $1,445.44
| Professional | | $575.44 | $691.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $245.47 / $512.86
| Professional | 26 | $117.49 | $245.47 | $512.86 |
- 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
- $457.09 / $562.34 / $1,000.00
| Professional | TC | $457.09 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,258.93 / $2,238.72
| Professional | | $1,071.52 | $1,258.93 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $281.84
| Professional | 26 | $239.88 | $239.88 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $954.99
| Professional | TC | $812.83 | $812.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $912.01 / $1,380.38
| Professional | | $812.83 | $912.01 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $177.83 / $275.42
| Professional | 26 | $154.88 | $177.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $645.65 / $741.31 / $1,000.00
| Professional | TC | $645.65 | $741.31 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $870.96 / $2,238.72
| Professional | | $741.31 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $173.78 / $426.58
| Professional | 26 | $144.54 | $173.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $588.84 / $691.83 / $691.83
| Professional | TC | $588.84 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,096.48 / $1,905.46
| Professional | | $724.44 | $1,096.48 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $229.09 / $295.12
| Professional | 26 | $131.83 | $229.09 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $537.03 / $851.14 / $1,258.93
| Professional | TC | $537.03 | $851.14 | $1,258.93 |