- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $30.90
| Facility | 26 | $15.85 | $15.85 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $52.48 / $138.04
| Professional | | $39.81 | $52.48 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $21.38 / $53.70
| Professional | 26 | $12.88 | $21.38 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $37.15 / $67.61
| Professional | TC | $25.70 | $37.15 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $67.61 / $100.00
| Professional | | $43.65 | $67.61 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $20.42 / $30.20
| Professional | 26 | $14.45 | $20.42 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $46.77 / $70.79
| Professional | TC | $28.84 | $46.77 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | 26 | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $58.88 / $104.71
| Professional | | $40.74 | $58.88 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $20.42 / $34.67
| Professional | 26 | $13.49 | $20.42 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $72.44
| Professional | TC | $26.92 | $38.90 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $81.28 / $208.93
| Professional | | $67.61 | $81.28 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $23.99 / $67.61
| Professional | 26 | $21.88 | $23.99 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $57.54 / $141.25
| Professional | TC | $51.29 | $57.54 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $51.29 / $77.62
| Professional | | $47.86 | $51.29 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $24.55
| Professional | 26 | $15.14 | $15.14 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $36.31 / $52.48
| Professional | TC | $32.36 | $36.31 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $70.79 / $104.71
| Professional | | $46.77 | $70.79 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $25.70 / $47.86
| Professional | 26 | $15.49 | $25.70 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $44.67 / $67.61
| Professional | TC | $30.90 | $44.67 | $67.61 |