- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.02 / $3.02 / $3.02
| Facility | 26 | $3.02 | $3.02 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $15.85 / $28.84
| Professional | | $12.88 | $15.85 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.00 / $3.02 / $6.03
| Professional | 26 | $2.00 | $3.02 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.96 / $12.88 / $22.91
| Professional | TC | $10.96 | $12.88 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $3.16 / $3.16
| Professional | | $3.16 | $3.16 | $3.16 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.65 / $3.02 / $4.37
| Facility | 26 | $0.65 | $3.02 | $4.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $23.99 / $100.00
| Professional | | $14.45 | $23.99 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.57 / $6.17 / $28.18
| Professional | 26 | $2.57 | $6.17 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.02 / $19.05 / $57.54
| Professional | TC | $12.02 | $19.05 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $22.39 / $37.15
| Professional | | $14.79 | $22.39 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.88 / $5.13 / $8.32
| Professional | 26 | $2.88 | $5.13 | $8.32 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $11.75 / $16.98 / $28.84
| Professional | TC | $11.75 | $16.98 | $28.84 |