- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $478.63 / $2,187.76
| Professional | | $169.82 | $478.63 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $549.54
| Professional | 26 | $102.33 | $199.53 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $426.58 / $891.25
| Professional | TC | $269.15 | $426.58 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $691.83
| Professional | | $158.49 | $158.49 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $194.98
| Facility | 26 | $158.49 | $158.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $812.83 / $1,096.48
| Professional | | $549.54 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $158.49 / $281.84
| Professional | 26 | $70.79 | $158.49 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $549.54 / $933.25
| Professional | TC | $257.04 | $549.54 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $645.65 / $1,122.02
| Professional | | $588.84 | $645.65 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $194.98
| Facility | 26 | $158.49 | $158.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $812.83 / $977.24
| Professional | | $549.54 | $812.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $234.42
| Professional | 26 | $104.71 | $158.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $467.74 / $870.96
| Professional | TC | $269.15 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $602.56 / $1,096.48
| Professional | | $338.84 | $602.56 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $234.42
| Professional | 26 | $87.10 | $93.33 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $457.09 / $891.25
| Professional | TC | $245.47 | $457.09 | $891.25 |