- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $19.95
| Facility | 26 | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $74.13 / $338.84
| Professional | | $53.70 | $74.13 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $19.50 / $40.74
| Professional | 26 | $12.02 | $19.50 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $52.48 / $158.49
| Professional | TC | $39.81 | $52.48 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $125.89
| Professional | | $64.57 | $85.11 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $22.91 / $33.88
| Professional | 26 | $15.49 | $22.91 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $54.95 / $91.20
| Professional | TC | $43.65 | $54.95 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $33.11 / $64.57
| Professional | | $30.90 | $33.11 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $131.83
| Professional | | $87.10 | $104.71 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $23.44 / $41.69
| Professional | 26 | $19.95 | $23.44 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $77.62 / $91.20
| Professional | TC | $67.61 | $77.62 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $95.50 / $120.23
| Professional | | $60.26 | $95.50 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.91 / $31.62
| Professional | 26 | $14.13 | $22.91 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $72.44 / $85.11
| Professional | TC | $45.71 | $72.44 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $66.07 / $109.65
| Professional | | $20.42 | $66.07 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $64.57 / $112.20
| Professional | | $56.23 | $64.57 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $18.20 / $30.20
| Professional | 26 | $14.45 | $18.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $45.71 / $83.18
| Professional | TC | $38.90 | $45.71 | $83.18 |