- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $199.53 / $1,000.00
| Professional | | $173.78 | $199.53 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $95.50 / $288.40
| Professional | 26 | $54.95 | $95.50 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $302.00
| Professional | TC | $117.49 | $138.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $275.42
| Professional | | $87.10 | $87.10 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $107.15
| Facility | 26 | $87.10 | $87.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $275.42 / $537.03
| Professional | | $144.54 | $275.42 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $87.10 / $165.96
| Professional | 26 | $46.77 | $87.10 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $190.55 / $371.54
| Professional | TC | $97.72 | $190.55 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $302.00 / $1,148.15
| Professional | | $295.12 | $302.00 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $107.15
| Facility | 26 | $87.10 | $87.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $251.19 / $354.81
| Professional | | $181.97 | $251.19 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $81.28 / $114.82
| Professional | 26 | $57.54 | $81.28 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $239.88
| Professional | TC | $123.03 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $309.03
| Professional | | $154.88 | $154.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $52.48 / $102.33
| Professional | 26 | $51.29 | $52.48 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $104.71 / $208.93
| Professional | TC | $102.33 | $104.71 | $208.93 |