- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $28.84 / $28.84
| Facility | 26 | $28.84 | $28.84 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $97.72 / $213.80
| Professional | | $48.98 | $97.72 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $40.74 / $91.20
| Professional | 26 | $24.55 | $40.74 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.00 / $23.99 / $112.20
| Professional | TC | $10.00 | $23.99 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.77 / $44.67 / $97.72
| Professional | | $9.77 | $44.67 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $48.98 / $69.18
| Facility | 26 | $10.47 | $48.98 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $128.82 / $389.05
| Professional | | $44.67 | $128.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $56.23 / $199.53
| Professional | 26 | $29.51 | $56.23 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $9.55 / $85.11 / $154.88
| Professional | TC | $9.55 | $85.11 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $89.13
| Professional | | $85.11 | $85.11 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Professional | 26 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $112.20 / $194.98
| Professional | | $64.57 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $30.90 / $64.57
| Professional | 26 | $21.88 | $30.90 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $75.86 / $151.36
| Professional | TC | $34.67 | $75.86 | $151.36 |