- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $34.67
| Facility | 26 | $19.95 | $19.95 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $93.33 / $194.98
| Professional | | $64.57 | $93.33 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $19.95 / $50.12
| Professional | 26 | $15.85 | $19.95 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $72.44 / $154.88
| Professional | TC | $51.29 | $72.44 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $229.09 / $251.19
| Professional | | $173.78 | $229.09 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $46.77 / $51.29
| Professional | 26 | $34.67 | $46.77 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $199.53
| Professional | TC | $138.04 | $181.97 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $234.42
| Professional | | $89.13 | $151.36 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $30.20 / $51.29
| Professional | 26 | $19.95 | $30.20 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $120.23 / $190.55
| Professional | TC | $67.61 | $120.23 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $630.96
| Professional | | $89.13 | $151.36 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $38.02 / $128.82
| Professional | 26 | $20.42 | $38.02 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $114.82 / $512.86
| Professional | TC | $69.18 | $114.82 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $162.18 / $229.09
| Professional | | $89.13 | $162.18 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $36.31 / $53.70
| Professional | 26 | $21.38 | $36.31 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $112.20 / $190.55
| Professional | TC | $66.07 | $112.20 | $190.55 |