- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | TC | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $52.48 / $89.13
| Professional | | $45.71 | $52.48 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $15.85 / $28.18
| Professional | 26 | $12.59 | $15.85 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $38.02 / $61.66
| Professional | TC | $33.11 | $38.02 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $177.83 / $177.83
| Professional | | $114.82 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $52.48 / $52.48
| Professional | 26 | $33.88 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $125.89 / $125.89
| Professional | TC | $81.28 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $79.43 / $131.83
| Professional | | $46.77 | $79.43 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $28.18 / $48.98
| Professional | 26 | $15.85 | $28.18 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $51.29 / $85.11
| Professional | TC | $32.36 | $51.29 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $77.62 / $138.04
| Professional | | $47.86 | $77.62 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $24.55 / $50.12
| Professional | 26 | $16.60 | $24.55 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $51.29 / $89.13
| Professional | TC | $30.90 | $51.29 | $89.13 |