- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $2,398.83 / $4,466.84
| Facility | | $346.74 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $870.96 / $1,621.81 / $2,630.27
| Facility | 25 | $870.96 | $1,621.81 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $426.58
| Professional | | $85.11 | $125.89 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $245.47 / $616.60
| Professional | 25 | $97.72 | $245.47 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $281.84
| Professional | | $104.71 | $147.91 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $208.93
| Professional | 25 | $93.33 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $323.59
| Professional | | $102.33 | $138.04 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $251.19
| Facility | | $97.72 | $125.89 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $208.93 / $741.31
| Professional | | $104.71 | $208.93 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $295.12 / $467.74 / $977.24
| Professional | 25 | $295.12 | $467.74 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $245.47
| Professional | | $97.72 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $173.78
| Professional | 25 | $79.43 | $89.13 | $173.78 |