- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $48.98
| Facility | 26 | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $47.86 / $162.18
| Professional | | $28.18 | $47.86 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $15.85 / $48.98
| Professional | 26 | $10.96 | $15.85 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $26.92 / $75.86
| Professional | TC | $15.85 | $26.92 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $123.03
| Professional | | $56.23 | $85.11 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $25.12 / $52.48
| Professional | 26 | $17.78 | $25.12 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $37.15 / $47.86 / $93.33
| Professional | TC | $37.15 | $47.86 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $48.98
| Facility | 26 | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $109.65 / $223.87
| Professional | | $50.12 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $44.67 / $93.33
| Professional | 26 | $17.78 | $44.67 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $70.79 / $151.36
| Professional | TC | $33.11 | $70.79 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $165.96 / $245.47
| Professional | | $154.88 | $165.96 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $60.26 / $100.00
| Professional | 26 | $56.23 | $60.26 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $107.15 / $147.91
| Professional | TC | $79.43 | $107.15 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $102.33 / $123.03
| Professional | | $52.48 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $21.88 / $56.23
| Professional | 26 | $12.88 | $21.88 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $47.86 / $72.44
| Professional | TC | $21.38 | $47.86 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $102.33 / $251.19
| Professional | | $48.98 | $102.33 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $44.67 / $95.50
| Professional | 26 | $17.78 | $44.67 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $61.66 / $117.49
| Professional | TC | $30.90 | $61.66 | $117.49 |