- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $12.02 / $12.02
| Facility | 26 | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $204.17
| Professional | | $54.95 | $83.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $15.14 / $77.62
| Professional | 26 | $10.72 | $15.14 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $199.53
| Professional | TC | $64.57 | $104.71 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Professional | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $177.83 / $223.87
| Professional | | $147.91 | $177.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $23.99 / $29.51
| Professional | 26 | $19.95 | $23.99 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $154.88 / $190.55
| Professional | TC | $128.82 | $154.88 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $162.18 / $776.25
| Professional | | $77.62 | $162.18 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $22.39 / $269.15
| Professional | 26 | $12.30 | $22.39 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $138.04 / $691.83
| Professional | TC | $77.62 | $138.04 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $194.98
| Professional | | $162.18 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $24.55 / $28.84
| Professional | 26 | $24.55 | $24.55 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $165.96
| Professional | TC | $138.04 | $138.04 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $162.18
| Professional | | $97.72 | $147.91 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $19.95 / $23.99
| Professional | 26 | $14.79 | $19.95 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $144.54
| Professional | TC | $83.18 | $128.82 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $204.17
| Professional | | $97.72 | $147.91 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $20.89 / $26.30
| Professional | 26 | $12.88 | $20.89 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $131.83 / $181.97
| Professional | TC | $85.11 | $131.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $177.83 / $186.21
| Professional | | $151.36 | $177.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $25.12 / $26.30
| Professional | 26 | $21.38 | $25.12 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $151.36 / $158.49
| Professional | TC | $128.82 | $151.36 | $158.49 |