- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $6.03
| Facility | 26 | $6.03 | $6.03 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.25 / $23.44 / $61.66
| Professional | 26 | $5.25 | $23.44 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $25.70 / $208.93
| Professional | TC | $18.20 | $25.70 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $21.38 / $22.39
| Facility | 26 | $18.62 | $21.38 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $60.26 / $87.10
| Professional | 26 | $35.48 | $60.26 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $194.98 / $281.84
| Professional | TC | $112.20 | $194.98 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $213.80
| Facility | 26 | $64.57 | $91.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $67.61 / $104.71
| Professional | 26 | $40.74 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $218.78 / $338.84
| Professional | TC | $131.83 | $218.78 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $87.10 / $169.82
| Facility | 26 | $69.18 | $87.10 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $61.66 / $95.50
| Professional | 26 | $40.74 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $309.03
| Professional | TC | $131.83 | $199.53 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 26 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $147.91 / $147.91
| Professional | 26 | $23.44 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $389.05 / $389.05
| Professional | TC | $74.13 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $58.88 / $100.00
| Professional | 26 | $34.67 | $58.88 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $194.98 / $323.59
| Professional | TC | $109.65 | $194.98 | $323.59 |