- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $123.03
| Facility | 26 | $12.88 | $12.88 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $50.12 / $75.86
| Professional | | $41.69 | $50.12 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.14 / $23.99
| Professional | 26 | $12.02 | $15.14 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $33.88 / $53.70
| Professional | TC | $28.84 | $33.88 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $41.69 / $114.82
| Professional | | $13.80 | $41.69 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $15.14 / $15.49
| Professional | 26 | $12.88 | $15.14 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $32.36 / $37.15
| Professional | TC | $28.84 | $32.36 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $95.50 / $204.17
| Professional | | $45.71 | $95.50 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $25.12 / $57.54
| Professional | 26 | $14.13 | $25.12 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $63.10 / $138.04
| Professional | TC | $29.51 | $63.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $45.71 / $109.65
| Professional | | $38.90 | $45.71 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $14.45 / $30.90
| Professional | 26 | $12.88 | $14.45 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $31.62 / $79.43
| Professional | TC | $25.70 | $31.62 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $69.18 / $128.82
| Professional | | $46.77 | $69.18 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $19.95 / $38.90
| Professional | 26 | $12.88 | $19.95 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $48.98 / $93.33
| Professional | TC | $33.88 | $48.98 | $93.33 |