- 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
- $45.71 / $70.79 / $134.90
| Professional | | $45.71 | $70.79 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $20.89 / $43.65
| Professional | 26 | $12.02 | $20.89 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $45.71 / $100.00
| Professional | TC | $30.90 | $45.71 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $64.57 / $93.33
| Professional | | $53.70 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $16.60 / $19.05
| Professional | 26 | $16.60 | $16.60 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $44.67
| Professional | TC | $44.67 | $44.67 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $57.54 / $74.13
| Professional | | $39.81 | $57.54 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $15.85 / $19.95
| Professional | 26 | $10.96 | $15.85 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $41.69 / $53.70
| Professional | TC | $29.51 | $41.69 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $66.07 / $131.83
| Professional | | $43.65 | $66.07 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $20.42 / $38.90
| Professional | 26 | $12.88 | $20.42 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $50.12 / $114.82
| Professional | TC | $34.67 | $50.12 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $57.54 / $102.33
| Professional | | $43.65 | $57.54 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $16.22 / $85.11
| Professional | 26 | $12.59 | $16.22 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $41.69 / $79.43
| Professional | TC | $30.90 | $41.69 | $79.43 |