- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $14.13
| Facility | 26 | $14.13 | $14.13 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $43.65 / $77.62
| Professional | | $28.84 | $43.65 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $15.14 / $43.65
| Professional | 26 | $11.48 | $15.14 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $30.20 / $41.69
| Professional | TC | $20.42 | $30.20 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $16.22
| Professional | | $16.22 | $16.22 | $16.22 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.55 / $16.60 / $23.44
| Facility | 26 | $3.55 | $16.60 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $66.07 / $208.93
| Professional | | $35.48 | $66.07 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $29.51 / $67.61
| Professional | 26 | $14.79 | $29.51 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.60 / $34.67 / $141.25
| Professional | TC | $16.60 | $34.67 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $34.67 / $53.70
| Professional | | $25.12 | $34.67 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $15.85 / $23.99
| Professional | 26 | $10.72 | $15.85 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $11.22 / $18.62 / $30.20
| Professional | TC | $11.22 | $18.62 | $30.20 |