- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,122.02 / $1,659.59
| Professional | | $794.33 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $120.23 / $158.49 / $257.04
| Professional | 26 | $120.23 | $158.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $660.69 / $870.96 / $1,380.38
| Professional | TC | $660.69 | $870.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,318.26 / $1,318.26
| Professional | | $1,071.52 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $199.53 / $199.53
| Professional | 26 | $158.49 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $741.31 / $912.01 / $912.01
| Professional | 53 | $741.31 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $912.01 / $1,122.02 / $1,122.02
| Professional | TC | $912.01 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,479.11 / $2,511.89
| Professional | | $1,000.00 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $281.84 / $501.19
| Professional | 26 | $190.55 | $281.84 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $758.58 / $1,258.93 / $1,995.26
| Professional | TC | $758.58 | $1,258.93 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,548.82 / $2,818.38
| Professional | | $1,122.02 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $186.21 / $269.15 / $588.84
| Professional | 26 | $186.21 | $269.15 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $912.01 / $1,318.26 / $2,344.23
| Professional | TC | $912.01 | $1,318.26 | $2,344.23 |