- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $323.59 / $446.68
| Professional | | $234.42 | $323.59 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $112.20 / $309.03
| Professional | 26 | $74.13 | $112.20 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $229.09 / $316.23
| Professional | TC | $162.18 | $229.09 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $407.38 / $724.44
| Professional | | $295.12 | $407.38 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $93.33 / $218.78
| Professional | 26 | $85.11 | $93.33 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $501.19
| Professional | TC | $208.93 | $223.87 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $616.60 / $1,000.00
| Professional | | $436.52 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $281.84
| Professional | 26 | $128.82 | $194.98 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $426.58 / $707.95
| Professional | TC | $309.03 | $426.58 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $407.38 / $575.44
| Professional | | $295.12 | $407.38 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $173.78
| Professional | 26 | $91.20 | $128.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $295.12 / $398.11
| Professional | TC | $199.53 | $295.12 | $398.11 |