- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $30.20 / $30.20
| Facility | 26 | $26.92 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $151.36
| Professional | | $91.20 | $117.49 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $26.92 / $58.88
| Professional | 26 | $23.99 | $26.92 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $91.20 / $117.49
| Professional | TC | $74.13 | $91.20 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $31.62 / $31.62
| Professional | | $31.62 | $31.62 | $31.62 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.76 / $31.62 / $44.67
| Facility | 26 | $6.76 | $31.62 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $588.84
| Professional | | $102.33 | $154.88 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $39.81 / $131.83
| Professional | 26 | $22.39 | $39.81 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $123.03 / $457.09
| Professional | TC | $75.86 | $123.03 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Professional | 26 | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $123.03 / $213.80
| Professional | | $77.62 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $31.62 / $57.54
| Professional | 26 | $19.50 | $31.62 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $91.20 / $154.88
| Professional | TC | $57.54 | $91.20 | $154.88 |