- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $10.72 / $10.72
| Facility | 26 | $10.72 | $10.72 | $10.72 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $457.09 / $457.09
| Facility | TC | $223.87 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $43.65 / $213.80
| Professional | | $34.67 | $43.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $12.88 / $25.12
| Professional | 26 | $10.96 | $12.88 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $30.90 / $50.12
| Professional | TC | $23.99 | $30.90 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $147.91
| Professional | | $95.50 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $43.65 / $43.65
| Professional | 26 | $28.18 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $102.33
| Professional | TC | $67.61 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $95.50
| Professional | | $38.90 | $58.88 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $20.89 / $33.11
| Professional | 26 | $12.30 | $20.89 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $42.66 / $61.66
| Professional | TC | $25.12 | $42.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $63.10 / $102.33
| Professional | | $31.62 | $63.10 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $20.42 / $36.31
| Professional | 26 | $11.22 | $20.42 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $41.69 / $67.61
| Professional | TC | $20.89 | $41.69 | $67.61 |