- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $42.66 / $199.53
| Professional | | $33.11 | $42.66 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.91 / $12.88 / $61.66
| Professional | 26 | $8.91 | $12.88 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $29.51 / $69.18
| Professional | TC | $22.91 | $29.51 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $50.12 / $77.62
| Professional | | $38.02 | $50.12 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $16.22 / $24.55
| Professional | 26 | $11.48 | $16.22 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $32.36 / $52.48
| Professional | TC | $25.12 | $32.36 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $32.36 / $45.71
| Professional | | $21.38 | $32.36 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $61.66 / $83.18
| Professional | | $52.48 | $61.66 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $16.98 / $28.18
| Professional | 26 | $14.45 | $16.98 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $44.67 / $54.95
| Professional | TC | $38.02 | $44.67 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $57.54 / $74.13
| Professional | | $35.48 | $57.54 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $16.60 / $23.99
| Professional | 26 | $10.23 | $16.60 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $41.69 / $48.98
| Professional | TC | $25.70 | $41.69 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $38.90 / $66.07
| Professional | | $14.79 | $38.90 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $39.81 / $66.07
| Professional | | $34.67 | $39.81 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $12.30 / $20.42
| Professional | 26 | $10.47 | $12.30 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $26.92 / $45.71
| Professional | TC | $24.55 | $26.92 | $45.71 |