- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | 26 | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $58.88 / $123.03
| Professional | | $35.48 | $58.88 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $15.14 / $33.11
| Professional | 26 | $12.59 | $15.14 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $34.67 / $72.44
| Professional | TC | $23.99 | $34.67 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $66.07
| Professional | | $20.42 | $20.42 | $66.07 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $25.12
| Facility | 26 | $20.42 | $20.42 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $57.54
| Facility | TC | $46.77 | $46.77 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $64.57 / $109.65
| Professional | | $31.62 | $64.57 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $20.42 / $36.31
| Professional | 26 | $11.22 | $20.42 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $40.74 / $72.44
| Professional | TC | $20.42 | $40.74 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $109.65
| Professional | | $63.10 | $74.13 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $25.12
| Facility | 26 | $20.42 | $20.42 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $57.54
| Facility | TC | $46.77 | $46.77 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $93.33 / $112.20
| Professional | | $53.70 | $93.33 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $20.42 / $30.20
| Professional | 26 | $13.18 | $20.42 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $42.66 / $66.07
| Professional | TC | $28.18 | $42.66 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $41.69 / $85.11
| Professional | | $39.81 | $41.69 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $15.14 / $38.90
| Professional | 26 | $14.13 | $15.14 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $27.54 / $48.98
| Professional | TC | $25.12 | $27.54 | $48.98 |