- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.61 / $6.61 / $6.61
| Facility | 26 | $6.61 | $6.61 | $6.61 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $416.87 / $436.52
| Facility | TC | $239.88 | $416.87 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $41.69 / $138.04
| Professional | | $11.48 | $41.69 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.03 / $10.72 / $30.90
| Professional | 26 | $6.03 | $10.72 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $41.69 / $81.28
| Professional | TC | $28.84 | $41.69 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $151.36 / $151.36
| Professional | | $97.72 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $26.92 / $26.92
| Professional | 26 | $16.98 | $26.92 | $26.92 |
- 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
- $33.88 / $61.66 / $95.50
| Professional | | $33.88 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.24 / $12.59 / $20.42
| Professional | 26 | $7.24 | $12.59 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $46.77 / $75.86
| Professional | TC | $25.12 | $46.77 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $60.26 / $102.33
| Professional | | $31.62 | $60.26 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.76 / $12.30 / $21.88
| Professional | 26 | $6.76 | $12.30 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $47.86 / $79.43
| Professional | TC | $24.55 | $47.86 | $79.43 |