- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $12.59 / $12.59
| Facility | 26 | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Facility | TC | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $47.86 / $85.11
| Professional | | $40.74 | $47.86 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $15.14 / $26.92
| Professional | 26 | $12.88 | $15.14 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $34.67 / $57.54
| Professional | TC | $26.92 | $34.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $165.96
| Professional | | $107.15 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $52.48 / $52.48
| Professional | 26 | $33.11 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $114.82 / $114.82
| Professional | TC | $75.86 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $69.18 / $109.65
| Professional | | $44.67 | $69.18 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $25.12 / $39.81
| Professional | 26 | $14.13 | $25.12 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $47.86 / $70.79
| Professional | TC | $28.84 | $47.86 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $72.44 / $120.23
| Professional | | $37.15 | $72.44 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $23.99 / $43.65
| Professional | 26 | $13.49 | $23.99 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $47.86 / $77.62
| Professional | TC | $23.99 | $47.86 | $77.62 |