- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.24 / $7.24 / $7.24
| Facility | 26 | $7.24 | $7.24 | $7.24 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.45 / $14.45 / $14.45
| Facility | TC | $14.45 | $14.45 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $23.99 / $42.66
| Professional | | $12.88 | $23.99 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $7.94 / $15.14
| Professional | 26 | $7.08 | $7.94 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $19.05 / $28.18
| Professional | TC | $15.14 | $19.05 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $85.11
| Professional | | $56.23 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $28.84 / $28.84
| Professional | 26 | $19.05 | $28.84 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $57.54 / $57.54
| Professional | TC | $37.15 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $40.74 / $66.07
| Professional | | $22.39 | $40.74 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.13 / $14.79 / $23.44
| Professional | 26 | $8.13 | $14.79 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.45 / $26.30 / $45.71
| Professional | TC | $14.45 | $26.30 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $37.15 / $69.18
| Professional | | $23.99 | $37.15 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.41 / $13.18 / $23.99
| Professional | 26 | $7.41 | $13.18 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $23.44 / $45.71
| Professional | TC | $16.22 | $23.44 | $45.71 |