- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $19.50
| Facility | 26 | $19.50 | $19.50 | $19.50 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $239.88 / $245.47
| Facility | TC | $77.62 | $239.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $40.74 / $70.79
| Professional | | $30.90 | $40.74 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $12.88 / $27.54
| Professional | 26 | $10.00 | $12.88 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $26.92 / $47.86
| Professional | TC | $20.89 | $26.92 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $10.00
| Professional | 26 | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $67.61 / $97.72
| Professional | | $41.69 | $67.61 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $19.50 / $28.84
| Professional | 26 | $12.30 | $19.50 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $46.77 / $61.66
| Professional | TC | $29.51 | $46.77 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $64.57 / $117.49
| Professional | | $43.65 | $64.57 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.39 / $37.15
| Professional | 26 | $14.13 | $22.39 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $46.77 / $83.18
| Professional | TC | $29.51 | $46.77 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $75.86 / $114.82
| Professional | | $47.86 | $75.86 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $21.88 / $33.11
| Professional | 26 | $14.45 | $21.88 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $53.70 / $81.28
| Professional | TC | $34.67 | $53.70 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $63.10 / $151.36
| Professional | | $45.71 | $63.10 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $19.95 / $38.02
| Professional | 26 | $13.80 | $19.95 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $41.69 / $91.20
| Professional | TC | $31.62 | $41.69 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.55 / $10.47 / $12.30
| Facility | 26 | $9.55 | $10.47 | $12.30 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $24.55 / $26.92 / $30.20
| Facility | TC | $24.55 | $26.92 | $30.20 |