- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $169.82
| Facility | 26 | $15.85 | $15.85 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $57.54 / $100.00
| Professional | | $38.02 | $57.54 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $19.95 / $48.98
| Professional | 26 | $15.85 | $19.95 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $30.90 / $54.95
| Professional | TC | $15.85 | $30.90 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $53.70 / $204.17
| Professional | | $19.05 | $53.70 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $18.62 / $20.89
| Professional | 26 | $16.60 | $18.62 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $35.48 / $35.48
| Professional | TC | $14.13 | $35.48 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $79.43 / $208.93
| Professional | | $44.67 | $79.43 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $32.36 / $74.13
| Professional | 26 | $17.38 | $32.36 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $38.02 / $134.90
| Professional | TC | $19.50 | $38.02 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $54.95 / $114.82
| Professional | | $45.71 | $54.95 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $19.05 / $38.90
| Professional | 26 | $16.60 | $19.05 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $36.31 / $75.86
| Professional | TC | $29.51 | $36.31 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $60.26 / $123.03
| Professional | | $35.48 | $60.26 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $26.30 / $48.98
| Professional | 26 | $16.98 | $26.30 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.49 / $34.67 / $74.13
| Professional | TC | $15.49 | $34.67 | $74.13 |