- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $43.65
| Facility | 26 | $6.03 | $6.03 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.01 / $23.99 / $64.57
| Professional | 26 | $5.01 | $23.99 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $57.54 / $213.80
| Professional | TC | $18.20 | $57.54 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $56.23 / $63.10
| Professional | 26 | $42.66 | $56.23 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $194.98
| Professional | TC | $134.90 | $177.83 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $46.77 / $79.43
| Professional | 26 | $36.31 | $46.77 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $151.36 / $257.04
| Professional | TC | $117.49 | $151.36 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $109.65
| Facility | 26 | $57.54 | $57.54 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $147.91 / $147.91
| Professional | 26 | $63.10 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $389.05 / $389.05
| Professional | TC | $204.17 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $48.98 / $72.44
| Professional | 26 | $28.18 | $48.98 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $245.47
| Professional | TC | $91.20 | $162.18 | $245.47 |