- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,000.00 / $2,951.21
| Facility | | $645.65 | $1,000.00 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $741.31 / $1,659.59 / $3,388.44
| Facility | 25 | $741.31 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $120.23 / $660.69
| Professional | | $85.11 | $120.23 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $95.50 / $223.87 / $758.58
| Professional | 25 | $95.50 | $223.87 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $141.25 / $288.40
| Professional | | $109.65 | $141.25 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $288.40
| Professional | 25 | $100.00 | $131.83 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,995.26 / $1,995.26
| Facility | | $1,584.89 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $316.23
| Professional | | $102.33 | $199.53 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $138.04 / $173.78
| Facility | | $112.20 | $138.04 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $181.97
| Professional | | $114.82 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $134.90 / $263.03
| Professional | | $102.33 | $134.90 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,344.23 / $3,630.78
| Facility | | $1,096.48 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $275.42
| Professional | | $97.72 | $125.89 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $173.78
| Professional | 25 | $79.43 | $85.11 | $173.78 |