- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $1,000.00 / $2,041.74
| Facility | | $177.83 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Facility | 26 | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $144.54 / $288.40
| Professional | | $109.65 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $57.54 / $165.96
| Professional | 26 | $35.48 | $57.54 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $114.82 / $186.21
| Professional | TC | $72.44 | $114.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $457.09 / $457.09
| Professional | | $295.12 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $151.36 / $151.36
| Professional | 26 | $97.72 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $309.03 / $309.03
| Professional | TC | $199.53 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $213.80 / $380.19
| Professional | | $117.49 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $72.44 / $114.82
| Professional | 26 | $38.90 | $72.44 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $134.90 / $245.47
| Professional | TC | $77.62 | $134.90 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $50.12 / $199.53
| Facility | | $24.55 | $50.12 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $239.88 / $457.09
| Professional | | $141.25 | $239.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $81.28 / $128.82
| Professional | 26 | $39.81 | $81.28 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $162.18 / $331.13
| Professional | TC | $102.33 | $162.18 | $331.13 |