- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $52.48 / $52.48
| Facility | 26 | $28.84 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $218.78
| Professional | | $57.54 | $70.79 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $47.86 / $218.78
| Professional | 26 | $15.85 | $47.86 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $52.48 / $169.82
| Professional | TC | $41.69 | $52.48 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $85.11 / $138.04
| Professional | | $60.26 | $85.11 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $19.05 / $28.84
| Professional | 26 | $13.49 | $19.05 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $50.12 / $66.07
| Professional | TC | $46.77 | $50.12 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $107.15 / $151.36
| Professional | | $42.66 | $107.15 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $30.90 / $34.67
| Professional | 26 | $10.96 | $30.90 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $75.86 / $117.49
| Professional | TC | $29.51 | $75.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $100.00 / $141.25
| Professional | | $41.69 | $100.00 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $23.99 / $35.48
| Professional | 26 | $11.48 | $23.99 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $75.86 / $107.15
| Professional | TC | $32.36 | $75.86 | $107.15 |