- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $43.65
| Facility | 26 | $10.00 | $10.00 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $10.47 / $53.70
| Professional | 26 | $8.91 | $10.47 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $16.60 / $64.57
| Professional | TC | $12.88 | $16.60 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $56.23 / $63.10
| Professional | 26 | $42.66 | $56.23 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $91.20
| Professional | TC | $61.66 | $83.18 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $46.77 / $79.43
| Professional | 26 | $36.31 | $46.77 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $120.23
| Professional | TC | $54.95 | $70.79 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $109.65
| Facility | 26 | $57.54 | $57.54 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Professional | TC | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $48.98 / $72.44
| Professional | 26 | $28.18 | $48.98 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $74.13 / $112.20
| Professional | TC | $41.69 | $74.13 | $112.20 |