- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $295.12
| Professional | | $114.82 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $28.84 / $74.13
| Professional | 26 | $20.89 | $28.84 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $199.53
| Professional | TC | $91.20 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $120.23 / $131.83
| Professional | | $85.11 | $120.23 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $24.55 / $26.92
| Professional | 26 | $17.38 | $24.55 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $95.50 / $104.71
| Professional | TC | $67.61 | $95.50 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $346.74
| Professional | | $95.50 | $154.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $26.30 / $72.44
| Professional | 26 | $18.62 | $26.30 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $138.04 / $309.03
| Professional | TC | $89.13 | $138.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $208.93
| Professional | | $97.72 | $131.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $23.44 / $33.88
| Professional | 26 | $19.05 | $23.44 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $104.71 / $181.97
| Professional | TC | $79.43 | $104.71 | $181.97 |