- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $851.14 / $851.14
| Professional | | $616.60 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $257.04 / $269.15
| Professional | 26 | $165.96 | $257.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $457.09 / $602.56 / $602.56
| Professional | TC | $457.09 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $891.25 / $1,071.52
| Professional | | $707.95 | $891.25 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $251.19 / $302.00
| Professional | 26 | $199.53 | $251.19 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $512.86 / $645.65 / $776.25
| Professional | TC | $512.86 | $645.65 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $562.34 / $724.44
| Professional | | $416.87 | $562.34 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $275.42
| Professional | 26 | $141.25 | $190.55 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $457.09 / $575.44
| Professional | TC | $275.42 | $457.09 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $707.95 / $1,071.52
| Professional | | $363.08 | $707.95 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $199.53 / $389.05
| Professional | 26 | $134.90 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $478.63 / $758.58
| Professional | TC | $229.09 | $478.63 | $758.58 |