- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $23.99 / $23.99
| Facility | 26 | $23.99 | $23.99 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $263.03
| Professional | | $114.82 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $23.99 / $51.29
| Professional | 26 | $20.89 | $23.99 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $112.20 / $239.88
| Professional | TC | $89.13 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $269.15 / $331.13
| Professional | | $223.87 | $269.15 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $47.86 / $58.88
| Professional | 26 | $39.81 | $47.86 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $218.78 / $275.42
| Professional | TC | $181.97 | $218.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $234.42 / $1,047.13
| Professional | | $117.49 | $234.42 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $43.65 / $302.00
| Professional | 26 | $21.88 | $43.65 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $912.01
| Professional | TC | $104.71 | $190.55 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $288.40
| Professional | | $239.88 | $239.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $47.86
| Professional | 26 | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $239.88
| Professional | TC | $194.98 | $194.98 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $213.80 / $239.88
| Professional | | $147.91 | $213.80 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $38.02 / $44.67
| Professional | 26 | $25.12 | $38.02 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $194.98
| Professional | TC | $120.23 | $173.78 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $223.87 / $346.74
| Professional | | $141.25 | $223.87 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $40.74 / $52.48
| Professional | 26 | $25.12 | $40.74 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $281.84
| Professional | TC | $114.82 | $181.97 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $269.15 / $275.42
| Professional | | $229.09 | $269.15 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $50.12 / $52.48
| Professional | 26 | $42.66 | $50.12 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $218.78 / $223.87
| Professional | TC | $186.21 | $218.78 | $223.87 |