- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $426.58 / $691.83 / $4,365.16
| Facility | 25 | $426.58 | $691.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $478.63
| Professional | | $87.10 | $120.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $257.04 / $776.25
| Professional | 25 | $97.72 | $257.04 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $229.09
| Professional | | $109.65 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $229.09
| Professional | 25 | $104.71 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $144.54 / $190.55
| Professional | | $117.49 | $144.54 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $275.42
| Professional | | $97.72 | $125.89 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $758.58 / $1,318.26
| Facility | | $616.60 | $758.58 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $109.65 / $177.83
| Professional | | $83.18 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $173.78
| Professional | 25 | $79.43 | $85.11 | $173.78 |