- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $2,089.30 / $4,073.80
| Facility | | $549.54 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $371.54 / $4,265.80 / $6,760.83
| Facility | 25 | $371.54 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $380.19
| Professional | | $91.20 | $128.82 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $112.20 / $275.42 / $812.83
| Professional | 25 | $112.20 | $275.42 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $199.53 / $426.58
| Professional | | $138.04 | $199.53 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $776.25
| Facility | | $123.03 | $173.78 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $371.54 / $4,570.88 / $7,244.36
| Facility | 25 | $371.54 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $269.15 / $562.34
| Professional | | $97.72 | $269.15 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $109.65 / $288.40 / $933.25
| Professional | 25 | $109.65 | $288.40 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $724.44 / $724.44
| Professional | | $281.84 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $309.03
| Facility | | $120.23 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $199.53 / $407.38
| Professional | | $79.43 | $199.53 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $302.00 / $549.54
| Professional | | $95.50 | $302.00 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $151.36
| Professional | 25 | $97.72 | $97.72 | $151.36 |