- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $524.81 / $1,737.80
| Professional | | $165.96 | $524.81 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $151.36 / $380.19
| Professional | 26 | $77.62 | $151.36 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $416.87 / $812.83
| Professional | TC | $269.15 | $416.87 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $512.86 / $512.86
| Professional | | $120.23 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $147.91
| Facility | 26 | $120.23 | $120.23 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $575.44 / $977.24
| Professional | | $398.11 | $575.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $120.23 / $213.80
| Professional | 26 | $53.70 | $120.23 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $478.63 / $758.58
| Professional | TC | $257.04 | $478.63 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $602.56 / $1,000.00
| Professional | | $549.54 | $602.56 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $147.91
| Facility | 26 | $120.23 | $120.23 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $724.44 / $891.25
| Professional | | $501.19 | $724.44 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $173.78
| Professional | 26 | $79.43 | $120.23 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $416.87 / $588.84
| Professional | TC | $269.15 | $416.87 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $446.68 / $776.25
| Professional | | $316.23 | $446.68 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $177.83
| Professional | 26 | $70.79 | $70.79 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $380.19 / $660.69
| Professional | TC | $245.47 | $380.19 | $660.69 |