- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $14.45 / $14.45
| Facility | 26 | $14.45 | $14.45 | $14.45 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | TC | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $53.70 / $93.33
| Professional | | $42.66 | $53.70 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $16.98 / $30.90
| Professional | 26 | $14.13 | $16.98 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $61.66
| Professional | TC | $28.18 | $37.15 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $181.97
| Professional | | $117.49 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $57.54 / $57.54
| Professional | 26 | $38.02 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $123.03 / $123.03
| Professional | TC | $79.43 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $74.13 / $117.49
| Professional | | $48.98 | $74.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $28.84 / $46.77
| Professional | 26 | $16.22 | $28.84 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $50.12 / $72.44
| Professional | TC | $29.51 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $79.43 / $128.82
| Professional | | $39.81 | $79.43 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $28.18 / $50.12
| Professional | 26 | $15.49 | $28.18 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $50.12 / $79.43
| Professional | TC | $24.55 | $50.12 | $79.43 |