- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $13.80 / $13.80
| Facility | 26 | $13.80 | $13.80 | $13.80 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $40.74
| Facility | TC | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $79.43 / $138.04
| Professional | | $50.12 | $79.43 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $15.85 / $30.20
| Professional | 26 | $13.18 | $15.85 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $47.86 / $77.62
| Professional | TC | $36.31 | $47.86 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $213.80 / $213.80
| Professional | | $138.04 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $56.23 / $56.23
| Professional | 26 | $36.31 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $158.49
| Professional | TC | $102.33 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $87.10 / $138.04
| Professional | | $56.23 | $87.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $26.92 / $43.65
| Professional | 26 | $15.49 | $26.92 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $64.57 / $93.33
| Professional | TC | $38.90 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $91.20 / $151.36
| Professional | | $46.77 | $91.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $26.30 / $46.77
| Professional | 26 | $14.45 | $26.30 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $64.57 / $102.33
| Professional | TC | $31.62 | $64.57 | $102.33 |