- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $7.08 / $7.08
| Facility | 26 | $7.08 | $7.08 | $7.08 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $199.53 / $275.42
| Facility | TC | $37.15 | $199.53 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $25.70 / $42.66
| Professional | | $16.98 | $25.70 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $8.32 / $23.99
| Professional | 26 | $7.08 | $8.32 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $19.05 / $30.90
| Professional | TC | $16.98 | $19.05 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $9.12 / $9.12
| Professional | | $9.12 | $9.12 | $9.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $1.95 / $9.12 / $13.18
| Facility | 26 | $1.95 | $9.12 | $13.18 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $5.01 / $23.44 / $33.88
| Facility | TC | $5.01 | $23.44 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $38.90 / $138.04
| Professional | | $22.39 | $38.90 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.46 / $11.48 / $37.15
| Professional | 26 | $6.46 | $11.48 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $26.92 / $102.33
| Professional | TC | $16.22 | $26.92 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | TC | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $13.80 / $21.38
| Professional | 26 | $12.59 | $13.80 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $30.20 / $54.95
| Professional | | $21.38 | $30.20 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.17 / $9.55 / $16.60
| Professional | 26 | $6.17 | $9.55 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $20.89 / $38.90
| Professional | TC | $15.14 | $20.89 | $38.90 |