- 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
- $123.03 / $151.36 / $194.98
| Professional | | $123.03 | $151.36 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $19.05 / $20.89
| Professional | 26 | $14.13 | $19.05 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $173.78
| Professional | TC | $107.15 | $134.90 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $173.78 / $398.11
| Professional | | $25.70 | $173.78 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $63.10 / $91.20
| Facility | 26 | $13.49 | $63.10 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $199.53 / $912.01
| Professional | | $89.13 | $199.53 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $38.90 / $204.17
| Professional | 26 | $10.23 | $38.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $173.78 / $794.33
| Professional | TC | $77.62 | $173.78 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Professional | | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $28.84 / $42.66
| Professional | 26 | $25.70 | $28.84 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $154.88 / $309.03
| Professional | | $87.10 | $154.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $35.48 / $85.11
| Professional | 26 | $13.80 | $35.48 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $117.49 / $234.42
| Professional | TC | $74.13 | $117.49 | $234.42 |