- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $199.53
| Facility | 26 | $21.88 | $21.88 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $138.04 / $281.84
| Professional | | $112.20 | $138.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $57.54
| Professional | 26 | $21.88 | $25.70 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $109.65 / $177.83
| Professional | TC | $91.20 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $134.90 / $630.96
| Professional | | $24.55 | $134.90 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $27.54
| Professional | 26 | $21.88 | $21.88 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $114.82 / $114.82
| Professional | TC | $104.71 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $389.05
| Professional | | $123.03 | $169.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $26.92 / $47.86
| Professional | 26 | $20.89 | $26.92 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $288.40
| Professional | TC | $97.72 | $141.25 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $144.54 / $295.12
| Professional | | $123.03 | $144.54 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $25.12 / $51.29
| Professional | 26 | $21.38 | $25.12 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $245.47
| Professional | TC | $100.00 | $117.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $371.54
| Professional | | $112.20 | $169.82 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $33.11 / $67.61
| Professional | 26 | $19.05 | $33.11 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $309.03
| Professional | TC | $89.13 | $147.91 | $309.03 |