- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $10.00
| Facility | 26 | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $39.81 / $169.82
| Professional | | $28.18 | $39.81 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.77 / $14.13 / $53.70
| Professional | 26 | $9.77 | $14.13 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $22.91 / $39.81
| Professional | TC | $18.20 | $22.91 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $30.90
| Professional | | $25.70 | $25.70 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $10.96 / $10.96
| Professional | 26 | $10.96 | $10.96 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $43.65 / $66.07
| Professional | | $29.51 | $43.65 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $14.79 / $24.55
| Professional | 26 | $10.47 | $14.79 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.20 / $28.84 / $40.74
| Professional | TC | $18.20 | $28.84 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $41.69 / $57.54
| Professional | | $29.51 | $41.69 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $15.49 / $22.39
| Professional | 26 | $10.23 | $15.49 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $26.30 / $36.31
| Professional | TC | $18.62 | $26.30 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.45 / $40.74 / $53.70
| Professional | | $0.45 | $40.74 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.45 / $13.80 / $17.78
| Professional | 26 | $0.45 | $13.80 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $0.45 / $26.92 / $36.31
| Professional | TC | $0.45 | $26.92 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.45 / $0.45 / $50.12
| Professional | | $0.45 | $0.45 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.45 / $0.45 / $16.60
| Professional | 26 | $0.45 | $0.45 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $0.45 / $0.45 / $33.88
| Professional | TC | $0.45 | $0.45 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $33.88 / $33.88
| Professional | | $29.51 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $10.96 / $10.96
| Professional | 26 | $10.00 | $10.96 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.50 / $22.91 / $22.91
| Professional | TC | $19.50 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $41.69 / $64.57
| Professional | | $30.20 | $41.69 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $17.38 / $26.92
| Professional | 26 | $11.48 | $17.38 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $27.54 / $43.65
| Professional | TC | $18.62 | $27.54 | $43.65 |