- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $17.38 / $17.38
| Facility | 26 | $17.38 | $17.38 | $17.38 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $38.02 / $39.81
| Facility | TC | $30.90 | $38.02 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $42.66 / $93.33
| Professional | | $30.20 | $42.66 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $16.98 / $35.48
| Professional | 26 | $10.00 | $16.98 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $28.84 / $61.66
| Professional | TC | $19.95 | $28.84 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $30.20 / $41.69
| Professional | | $25.70 | $30.20 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $9.33 / $14.79
| Professional | 26 | $9.33 | $9.33 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $72.44 / $93.33
| Professional | | $50.12 | $72.44 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $29.51 / $38.02
| Professional | 26 | $20.42 | $29.51 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $42.66 / $54.95
| Professional | TC | $30.20 | $42.66 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $45.71 / $91.20
| Professional | | $30.20 | $45.71 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $17.38 / $30.90
| Professional | 26 | $10.96 | $17.38 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $30.90 / $61.66
| Professional | TC | $22.39 | $30.90 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $39.81 / $75.86
| Professional | | $30.20 | $39.81 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $13.80 / $75.86
| Professional | 26 | $10.47 | $13.80 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $26.92 / $50.12
| Professional | TC | $19.50 | $26.92 | $50.12 |