- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $19.50 / $19.50
| Facility | 26 | $13.49 | $19.50 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $75.86 / $158.49
| Professional | | $48.98 | $75.86 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $22.91 / $61.66
| Professional | 26 | $12.02 | $22.91 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $52.48 / $107.15
| Professional | TC | $34.67 | $52.48 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $47.86 / $75.86
| Professional | | $38.02 | $47.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $15.14 / $16.98
| Professional | 26 | $10.96 | $15.14 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $45.71
| Professional | TC | $38.02 | $38.02 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $102.33 / $131.83
| Professional | | $70.79 | $102.33 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $29.51 / $38.02
| Professional | 26 | $20.42 | $29.51 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $72.44 / $93.33
| Professional | TC | $51.29 | $72.44 | $93.33 |
- 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
- $44.67 / $72.44 / $131.83
| Professional | | $44.67 | $72.44 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $20.89 / $38.90
| Professional | 26 | $12.88 | $20.89 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $54.95 / $114.82
| Professional | TC | $38.02 | $54.95 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $58.88 / $107.15
| Professional | | $46.77 | $58.88 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $15.49 / $85.11
| Professional | 26 | $12.30 | $15.49 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $42.66 / $69.18
| Professional | TC | $33.11 | $42.66 | $69.18 |