- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $524.81 / $1,000.00
| Facility | | $263.03 | $524.81 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | 26 | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $316.23 / $323.59 / $691.83
| Facility | TC | $316.23 | $323.59 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $1,148.15
| Professional | | $173.78 | $251.19 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $46.77 / $154.88
| Professional | 26 | $31.62 | $46.77 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $194.98 / $446.68
| Professional | TC | $144.54 | $194.98 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $501.19 / $602.56
| Facility | | $316.23 | $501.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $229.09 / $371.54
| Professional | | $173.78 | $229.09 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $39.81 / $69.18
| Professional | 26 | $27.54 | $39.81 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $190.55 / $257.04
| Professional | TC | $134.90 | $190.55 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $794.33 / $1,148.15
| Facility | | $660.69 | $794.33 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $245.47 / $416.87
| Professional | | $181.97 | $245.47 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $44.67 / $70.79
| Professional | 26 | $31.62 | $44.67 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $204.17 / $338.84
| Professional | TC | $165.96 | $204.17 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $371.54
| Professional | | $177.83 | $239.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $39.81 / $64.57
| Professional | 26 | $32.36 | $39.81 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $309.03
| Professional | TC | $151.36 | $204.17 | $309.03 |