- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Facility | 26 | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $97.72 / $158.49
| Professional | | $54.95 | $97.72 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $22.91 / $39.81
| Professional | 26 | $12.02 | $22.91 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $72.44 / $123.03
| Professional | TC | $41.69 | $72.44 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $117.49
| Professional | | $91.20 | $100.00 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $23.99 / $30.90
| Professional | 26 | $23.99 | $23.99 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $75.86 / $89.13
| Professional | TC | $64.57 | $75.86 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $18.62 / $18.62
| Professional | 26 | $18.20 | $18.62 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $144.54
| Professional | | $37.15 | $56.23 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.12 / $15.85 / $35.48
| Professional | 26 | $9.12 | $15.85 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $35.48 / $104.71
| Professional | TC | $28.18 | $35.48 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $87.10 / $165.96
| Professional | | $47.86 | $87.10 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $22.91 / $39.81
| Professional | 26 | $13.49 | $22.91 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $70.79 / $125.89
| Professional | TC | $39.81 | $70.79 | $125.89 |