- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $316.23 / $724.44
| Professional | | $257.04 | $316.23 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $309.03
| Professional | 26 | $169.82 | $199.53 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $177.83
| Professional | TC | $91.20 | $114.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $512.86 / $512.86
| Professional | | $416.87 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $263.03 / $323.59 / $323.59
| Professional | 26 | $263.03 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $186.21 / $186.21
| Professional | TC | $151.36 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $489.78 / $660.69
| Professional | | $389.05 | $489.78 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $251.19 / $309.03 / $416.87
| Professional | 26 | $251.19 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $251.19
| Professional | TC | $141.25 | $177.83 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $524.81 / $1,000.00
| Professional | | $407.38 | $524.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $245.47 / $346.74 / $616.60
| Professional | 26 | $245.47 | $346.74 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $371.54
| Professional | TC | $138.04 | $190.55 | $371.54 |