- 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
- $117.49 / $141.25 / $208.93
| Professional | | $117.49 | $141.25 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $23.99 / $38.90
| Professional | 26 | $20.89 | $23.99 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $19.05 / $19.05
| Facility | 26 | $15.85 | $19.05 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $371.54 / $524.81
| Professional | | $223.87 | $371.54 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $57.54 / $81.28
| Professional | 26 | $35.48 | $57.54 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $79.43 / $190.55
| Facility | 26 | $37.15 | $79.43 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $380.19 / $630.96
| Professional | | $169.82 | $380.19 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $57.54 / $91.20
| Professional | 26 | $27.54 | $57.54 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $77.62 / $151.36
| Facility | 26 | $61.66 | $77.62 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $371.54 / $575.44
| Professional | | $251.19 | $371.54 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $54.95 / $85.11
| Professional | 26 | $37.15 | $54.95 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | 26 | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $269.15 / $851.14
| Professional | | $147.91 | $269.15 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $43.65 / $147.91
| Professional | 26 | $24.55 | $43.65 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $275.42 / $489.78
| Professional | | $154.88 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $42.66 / $77.62
| Professional | 26 | $25.12 | $42.66 | $77.62 |