- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $467.74
| Professional | | $177.83 | $239.88 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $48.98 / $72.44
| Professional | 26 | $40.74 | $48.98 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $199.53 / $363.08
| Professional | TC | $134.90 | $199.53 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $1,000.00
| Professional | | $363.08 | $363.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $389.05 / $1,000.00
| Professional | | $288.40 | $389.05 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $60.26 / $165.96
| Professional | 26 | $38.90 | $60.26 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $288.40 / $630.96
| Professional | TC | $239.88 | $288.40 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $281.84 / $1,000.00
| Professional | | $275.42 | $281.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $50.12 / $165.96
| Professional | 26 | $46.77 | $50.12 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $239.88 / $489.78
| Professional | TC | $229.09 | $239.88 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $407.38 / $691.83
| Professional | | $251.19 | $407.38 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $66.07 / $109.65
| Professional | 26 | $42.66 | $66.07 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $338.84 / $524.81
| Professional | TC | $208.93 | $338.84 | $524.81 |