- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $371.54 / $794.33
| Professional | | $213.80 | $371.54 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $251.19
| Professional | 26 | $56.23 | $97.72 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $269.15 / $501.19
| Professional | TC | $154.88 | $269.15 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $316.23 / $316.23
| Professional | | $91.20 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $114.82
| Facility | 26 | $91.20 | $91.20 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $407.38 / $616.60
| Professional | | $288.40 | $407.38 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $91.20 / $173.78
| Professional | 26 | $40.74 | $91.20 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $323.59 / $467.74
| Professional | TC | $151.36 | $323.59 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $371.54 / $588.84
| Professional | | $346.74 | $371.54 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $114.82
| Facility | 26 | $91.20 | $91.20 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $457.09 / $549.54
| Professional | | $309.03 | $457.09 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $93.33 / $134.90
| Professional | 26 | $61.66 | $93.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $269.15 / $338.84
| Professional | TC | $154.88 | $269.15 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $302.00 / $512.86
| Professional | | $199.53 | $302.00 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $134.90
| Professional | 26 | $60.26 | $60.26 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $245.47 / $407.38
| Professional | TC | $141.25 | $245.47 | $407.38 |