- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $12.30 / $12.30
| Facility | 26 | $12.30 | $12.30 | $12.30 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | TC | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $51.29 / $87.10
| Professional | | $40.74 | $51.29 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $15.14 / $26.92
| Professional | 26 | $12.30 | $15.14 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $36.31 / $75.86
| Professional | TC | $28.18 | $36.31 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $169.82
| Professional | | $109.65 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $50.12 / $50.12
| Professional | 26 | $33.11 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $120.23 / $120.23
| Professional | TC | $77.62 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $69.18 / $109.65
| Professional | | $45.71 | $69.18 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $24.55 / $39.81
| Professional | 26 | $14.13 | $24.55 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $48.98 / $70.79
| Professional | TC | $28.84 | $48.98 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $74.13 / $120.23
| Professional | | $37.15 | $74.13 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $23.44 / $42.66
| Professional | 26 | $13.18 | $23.44 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $48.98 / $77.62
| Professional | TC | $23.99 | $48.98 | $77.62 |