- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.50 / $5.50 / $5.50
| Facility | 26 | $5.50 | $5.50 | $5.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $38.90 / $114.82
| Professional | | $21.38 | $38.90 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.82 / $4.07 / $11.22
| Professional | 26 | $2.82 | $4.07 | $11.22 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $5.75 / $5.75 / $5.75
| Professional | 52 | $5.75 | $5.75 | $5.75 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $25.12 / $56.23
| Professional | TC | $19.05 | $25.12 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $21.88 / $28.84
| Professional | | $17.78 | $21.88 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.75 / $3.72 / $4.47
| Professional | 26 | $2.75 | $3.72 | $4.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $48.98 / $53.70
| Professional | | $17.78 | $48.98 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.40 / $3.47 / $3.80
| Professional | 26 | $2.40 | $3.47 | $3.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $44.67 / $50.12
| Professional | TC | $15.14 | $44.67 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $38.02 / $109.65
| Professional | | $18.20 | $38.02 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.16 / $5.01 / $9.77
| Professional | 26 | $3.16 | $5.01 | $9.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $39.81 / $104.71
| Professional | TC | $19.50 | $39.81 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $25.12 / $117.49
| Professional | | $19.05 | $25.12 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.45 / $3.24 / $6.61
| Professional | 26 | $2.45 | $3.24 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.60 / $21.88 / $107.15
| Professional | TC | $16.60 | $21.88 | $107.15 |