- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $288.40 / $602.56
| Professional | | $223.87 | $288.40 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $223.87
| Professional | 26 | $72.44 | $100.00 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $380.19
| Professional | TC | $144.54 | $190.55 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $331.13 / $812.83
| Professional | | $229.09 | $331.13 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $117.49 / $269.15
| Professional | 26 | $79.43 | $117.49 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $218.78 / $537.03
| Professional | TC | $147.91 | $218.78 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $380.19 / $660.69
| Professional | | $263.03 | $380.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $114.82 / $190.55
| Professional | 26 | $83.18 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $446.68
| Professional | TC | $173.78 | $251.19 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $346.74 / $660.69
| Professional | | $275.42 | $346.74 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $229.09
| Professional | 26 | $97.72 | $123.03 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $229.09 / $426.58
| Professional | TC | $181.97 | $229.09 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $302.00 / $660.69
| Professional | | $229.09 | $302.00 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $194.98
| Professional | 26 | $77.62 | $102.33 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $204.17 / $426.58
| Professional | TC | $158.49 | $204.17 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $389.05 / $676.08
| Professional | | $239.88 | $389.05 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $123.03 / $338.84
| Professional | 26 | $85.11 | $123.03 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $263.03 / $426.58
| Professional | TC | $162.18 | $263.03 | $426.58 |