- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $21.88
| Facility | 26 | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $138.04 / $199.53
| Professional | | $112.20 | $138.04 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $23.99 / $30.90
| Professional | 26 | $20.89 | $23.99 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $141.25 / $194.98
| Professional | | $22.91 | $141.25 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $36.31
| Facility | 26 | $36.31 | $36.31 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $181.97 / $229.09
| Professional | | $134.90 | $181.97 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $31.62 / $38.90
| Professional | 26 | $23.99 | $31.62 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $102.33 / $102.33
| Facility | 26 | $52.48 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $851.14
| Professional | | $134.90 | $165.96 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.18 / $147.91
| Professional | 26 | $21.88 | $28.18 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $158.49 / $239.88
| Professional | | $123.03 | $158.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $25.70 / $38.90
| Professional | 26 | $20.42 | $25.70 | $38.90 |