- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $33.88 / $117.49
| Facility | 26 | $19.95 | $33.88 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $52.48 / $100.00
| Professional | | $30.20 | $52.48 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $21.88 / $42.66
| Professional | 26 | $18.20 | $21.88 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.00 / $30.90 / $56.23
| Professional | TC | $10.00 | $30.90 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $46.77 / $104.71
| Professional | | $30.20 | $46.77 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $26.30 / $51.29
| Professional | 26 | $19.05 | $26.30 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.00 / $16.22 / $63.10
| Professional | TC | $10.00 | $16.22 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.01 / $26.92 / $74.13
| Facility | 26 | $5.01 | $26.92 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $63.10 / $162.18
| Professional | | $37.15 | $63.10 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $30.90 / $66.07
| Professional | 26 | $21.38 | $30.90 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.02 / $34.67 / $97.72
| Professional | TC | $12.02 | $34.67 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $52.48 / $120.23
| Professional | | $31.62 | $52.48 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $26.92 / $53.70
| Professional | 26 | $18.20 | $26.92 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $10.23 / $27.54 / $69.18
| Professional | TC | $10.23 | $27.54 | $69.18 |