- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $6.46 / $33.11
| Facility | 26 | $6.03 | $6.46 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.50 / $12.02 / $75.86
| Professional | 26 | $5.50 | $12.02 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $21.38 / $104.71
| Professional | TC | $18.20 | $21.38 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $29.51 / $41.69
| Professional | 26 | $23.44 | $29.51 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $33.11 / $77.62
| Professional | 26 | $23.44 | $33.11 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $102.33 / $234.42
| Professional | TC | $74.13 | $102.33 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $37.15 / $66.07
| Professional | 26 | $26.92 | $37.15 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $112.20 / $199.53
| Professional | TC | $81.28 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $30.20 / $39.81
| Professional | 26 | $22.39 | $30.20 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $91.20 / $131.83
| Professional | TC | $67.61 | $91.20 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $194.98
| Professional | 26 | $144.54 | $144.54 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $645.65
| Professional | TC | $416.87 | $416.87 | $645.65 |