- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Facility | 26 | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | TC | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $48.98 / $109.65
| Professional | | $34.67 | $48.98 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $19.95 / $54.95
| Professional | 26 | $12.02 | $19.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $30.90 / $60.26
| Professional | TC | $20.89 | $30.90 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $56.23 / $100.00
| Professional | | $38.90 | $56.23 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $16.60 / $33.88
| Professional | 26 | $11.48 | $16.60 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $38.02 / $52.48
| Professional | TC | $27.54 | $38.02 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $67.61 / $104.71
| Professional | | $40.74 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $22.91 / $36.31
| Professional | 26 | $15.14 | $22.91 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $50.12 / $74.13
| Professional | TC | $28.84 | $50.12 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $53.70 / $74.13
| Professional | | $42.66 | $53.70 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $16.98 / $26.30
| Professional | 26 | $14.79 | $16.98 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $43.65
| Professional | TC | $28.18 | $37.15 | $43.65 |