- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Facility | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $524.81 / $912.01 / $1,000.00
| Facility | 25 | $524.81 | $912.01 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $63.10 / $104.71
| Professional | | $51.29 | $63.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $63.10 / $97.72 / $204.17
| Professional | 25 | $63.10 | $97.72 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $67.61 / $123.03
| Professional | | $57.54 | $67.61 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $63.10 / $67.61 / $123.03
| Professional | 25 | $63.10 | $67.61 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $851.14
| Facility | | $467.74 | $588.84 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $72.44 / $97.72
| Professional | | $70.79 | $72.44 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $77.62 / $112.20
| Professional | | $63.10 | $77.62 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $263.03
| Facility | | $66.07 | $87.10 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $426.58
| Facility | 25 | $354.81 | $354.81 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $501.19
| Professional | | $57.54 | $77.62 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $100.00
| Professional | 25 | $67.61 | $87.10 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $66.07 / $100.00
| Professional | | $53.70 | $66.07 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $89.13 / $169.82 / $199.53
| Professional | 25 | $89.13 | $169.82 | $199.53 |