- 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
- $144.54 / $177.83 / $389.05
| Professional | | $144.54 | $177.83 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.18 / $64.57
| Professional | 26 | $21.88 | $28.18 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $239.88
| Professional | TC | $123.03 | $147.91 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $177.83 / $707.95
| Professional | | $27.54 | $177.83 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $26.30 / $27.54
| Professional | 26 | $23.44 | $26.30 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $181.97
| Professional | TC | $147.91 | $147.91 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $218.78 / $446.68
| Professional | | $154.88 | $218.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $29.51 / $56.23
| Professional | 26 | $21.88 | $29.51 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $190.55 / $398.11
| Professional | TC | $131.83 | $190.55 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $380.19
| Professional | | $162.18 | $190.55 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $51.29
| Professional | 26 | $21.88 | $25.70 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $331.13
| Professional | TC | $141.25 | $165.96 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $218.78 / $489.78
| Professional | | $141.25 | $218.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $50.12 / $77.62
| Professional | 26 | $21.38 | $50.12 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $199.53 / $416.87
| Professional | TC | $120.23 | $199.53 | $416.87 |