- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $1,621.81 / $2,754.23
| Facility | | $281.84 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $251.19 / $1,380.38 / $2,884.03
| Facility | 25 | $251.19 | $1,380.38 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $70.79 / $234.42
| Professional | | $51.29 | $70.79 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $66.07 / $141.25 / $331.13
| Professional | 25 | $66.07 | $141.25 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $67.61 / $123.03
| Professional | | $60.26 | $67.61 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $54.95 / $72.44 / $123.03
| Professional | 25 | $54.95 | $72.44 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $177.83
| Professional | | $58.88 | $77.62 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $70.79 / $131.83
| Facility | | $56.23 | $70.79 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $501.19
| Professional | | $56.23 | $97.72 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $141.25 / $162.18 / $302.00
| Professional | 25 | $141.25 | $162.18 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $141.25
| Professional | | $53.70 | $67.61 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $91.20
| Professional | 25 | $89.13 | $89.13 | $91.20 |