- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $389.05 / $691.83
| Professional | | $263.03 | $389.05 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $194.98
| Professional | 26 | $89.13 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $309.03 / $407.38
| Professional | TC | $169.82 | $309.03 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | 26 | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $1,584.89
| Professional | | $489.78 | $489.78 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $371.54
| Professional | 26 | $120.23 | $120.23 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $426.58
| Professional | TC | $363.08 | $363.08 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $660.69 / $1,288.25
| Professional | | $436.52 | $660.69 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $131.83 / $281.84
| Professional | 26 | $114.82 | $131.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $524.81 / $1,000.00
| Professional | TC | $218.78 | $524.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Professional | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | 26 | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Professional | TC | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $489.78 / $1,148.15
| Professional | | $323.59 | $489.78 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $234.42
| Professional | 26 | $91.20 | $117.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $354.81 / $741.31
| Professional | TC | $223.87 | $354.81 | $741.31 |