- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $741.31 / $2,754.23
| Professional | | $478.63 | $741.31 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $190.55 / $338.84
| Professional | 26 | $107.15 | $190.55 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $501.19 / $1,071.52
| Professional | TC | $338.84 | $501.19 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $1,071.52
| Professional | | $165.96 | $165.96 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $204.17
| Facility | 26 | $165.96 | $165.96 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $954.99 / $1,479.11
| Professional | | $645.65 | $954.99 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $165.96 / $295.12
| Professional | 26 | $74.13 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $398.11 / $758.58 / $1,174.90
| Professional | TC | $398.11 | $758.58 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $870.96 / $1,258.93
| Professional | | $831.76 | $870.96 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $204.17
| Facility | 26 | $165.96 | $165.96 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,096.48 / $1,348.96
| Professional | | $758.58 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $245.47
| Professional | 26 | $109.65 | $165.96 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $416.87 / $645.65 / $891.25
| Professional | TC | $416.87 | $645.65 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $676.08 / $1,230.27
| Professional | | $478.63 | $676.08 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $251.19
| Professional | 26 | $91.20 | $100.00 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $380.19 / $616.60 / $1,000.00
| Professional | TC | $380.19 | $616.60 | $1,000.00 |