- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $7.94 / $7.94
| Facility | 26 | $7.94 | $7.94 | $7.94 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $21.38
| Facility | TC | $21.38 | $21.38 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $34.67 / $57.54
| Professional | | $30.20 | $34.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $8.91 / $20.42
| Professional | 26 | $7.94 | $8.91 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $40.74
| Professional | TC | $21.88 | $25.70 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $117.49
| Professional | | $77.62 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $32.36 / $32.36
| Professional | 26 | $20.89 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $85.11
| Professional | TC | $56.23 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $48.98 / $79.43
| Professional | | $30.20 | $48.98 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $15.14 / $23.99
| Professional | 26 | $8.91 | $15.14 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $34.67 / $53.70
| Professional | TC | $21.88 | $34.67 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $51.29 / $85.11
| Professional | | $26.30 | $51.29 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.13 / $14.79 / $26.30
| Professional | 26 | $8.13 | $14.79 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $36.31 / $58.88
| Professional | TC | $18.20 | $36.31 | $58.88 |