- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $34.67
| Facility | 26 | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $151.36
| Professional | | $56.23 | $67.61 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $36.31 / $75.86
| Professional | 26 | $25.70 | $36.31 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $33.88 / $64.57
| Professional | TC | $28.84 | $33.88 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $72.44
| Professional | | $67.61 | $67.61 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $27.54 / $27.54
| Professional | 26 | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $112.20 / $131.83
| Professional | | $69.18 | $112.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $52.48 / $63.10
| Professional | 26 | $31.62 | $52.48 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $60.26 / $70.79
| Professional | TC | $38.02 | $60.26 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $75.86 / $158.49
| Professional | | $57.54 | $75.86 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $38.02 / $67.61
| Professional | 26 | $27.54 | $38.02 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $39.81 / $91.20
| Professional | TC | $29.51 | $39.81 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $58.88 / $93.33
| Professional | | $43.65 | $58.88 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $29.51 / $45.71
| Professional | 26 | $21.38 | $29.51 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.88 / $30.20 / $44.67
| Professional | TC | $21.88 | $30.20 | $44.67 |