- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $22.91
| Facility | 26 | $22.91 | $22.91 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $128.82 / $213.80
| Professional | | $93.33 | $128.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $22.91 / $48.98
| Professional | 26 | $18.20 | $22.91 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $181.97 / $275.42
| Professional | | $104.71 | $181.97 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $30.90 / $45.71
| Professional | 26 | $22.91 | $30.90 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $46.77
| Facility | 26 | $46.77 | $46.77 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $144.54 / $275.42
| Professional | | $95.50 | $144.54 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $30.90 / $53.70
| Professional | 26 | $20.89 | $30.90 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $218.78 / $407.38
| Professional | | $169.82 | $218.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $36.31 / $109.65
| Professional | 26 | $32.36 | $36.31 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $204.17
| Professional | | $125.89 | $138.04 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $22.91 / $36.31
| Professional | 26 | $22.39 | $22.91 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $173.78 / $269.15
| Professional | | $107.15 | $173.78 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $39.81 / $67.61
| Professional | 26 | $23.99 | $39.81 | $67.61 |