- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $602.56 / $1,819.70
| Professional | | $346.74 | $602.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $144.54 / $416.87
| Professional | 26 | $77.62 | $144.54 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $426.58 / $758.58
| Professional | TC | $269.15 | $426.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $512.86
| Professional | | $120.23 | $120.23 | $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
- $407.38 / $588.84 / $1,000.00
| Professional | | $407.38 | $588.84 | $1,000.00 |
- 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 / $489.78 / $758.58
| Professional | TC | $257.04 | $489.78 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $602.56 / $1,023.29
| Professional | | $549.54 | $602.56 | $1,023.29 |
- 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 / $912.01
| Professional | | $501.19 | $724.44 | $912.01 |
- 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 / $457.09 / $794.33
| Professional | | $316.23 | $457.09 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $72.44 / $177.83
| Professional | 26 | $70.79 | $72.44 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $363.08 / $645.65
| Professional | TC | $245.47 | $363.08 | $645.65 |