- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Facility | 26 | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $97.72 / $162.18
| Professional | | $67.61 | $97.72 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.18 / $77.62
| Professional | 26 | $21.88 | $28.18 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $72.44 / $117.49
| Professional | TC | $51.29 | $72.44 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $35.48 / $38.02
| Professional | 26 | $22.39 | $35.48 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $100.00 / $134.90
| Professional | | $28.18 | $100.00 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $44.67
| Facility | 26 | $44.67 | $44.67 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $97.72 / $151.36
| Professional | | $77.62 | $97.72 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $28.84 / $45.71
| Professional | 26 | $22.91 | $28.84 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $104.71
| Professional | TC | $56.23 | $67.61 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $128.82 / $128.82
| Facility | 26 | $67.61 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $676.08
| Professional | | $93.33 | $117.49 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $33.11 / $181.97
| Professional | 26 | $25.12 | $33.11 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $83.18 / $489.78
| Professional | TC | $66.07 | $83.18 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $165.96
| Professional | | $87.10 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $31.62 / $57.54
| Professional | 26 | $25.12 | $31.62 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $79.43 / $109.65
| Professional | TC | $61.66 | $79.43 | $109.65 |