- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $10.00
| Facility | 26 | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $12.02 / $34.67
| Professional | 26 | $8.91 | $12.02 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $16.60 / $43.65
| Professional | TC | $12.88 | $16.60 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $21.38 / $22.39
| Facility | 26 | $18.62 | $21.38 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $60.26 / $87.10
| Professional | 26 | $35.48 | $60.26 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $91.20 / $131.83
| Professional | TC | $53.70 | $91.20 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $213.80
| Facility | 26 | $64.57 | $91.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $67.61 / $104.71
| Professional | 26 | $40.74 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $102.33 / $158.49
| Professional | TC | $61.66 | $102.33 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $87.10 / $169.82
| Facility | 26 | $69.18 | $87.10 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $61.66 / $95.50
| Professional | 26 | $40.74 | $61.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $93.33 / $144.54
| Professional | TC | $61.66 | $93.33 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 26 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $147.91 / $147.91
| Professional | 26 | $23.44 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $181.97 / $181.97
| Professional | TC | $34.67 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $58.88 / $100.00
| Professional | 26 | $34.67 | $58.88 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $91.20 / $151.36
| Professional | TC | $51.29 | $91.20 | $151.36 |