- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $1,000.00 / $1,819.70
| Facility | | $524.81 | $1,000.00 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $741.31 / $1,023.29 / $1,949.84
| Facility | 25 | $741.31 | $1,023.29 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $371.54
| Professional | | $87.10 | $120.23 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $95.50 / $229.09 / $524.81
| Professional | 25 | $95.50 | $229.09 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $1,258.93
| Facility | | $562.34 | $562.34 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $309.03 / $398.11
| Professional | | $190.55 | $309.03 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $151.36 / $251.19 / $323.59
| Professional | 25 | $151.36 | $251.19 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $851.14 / $1,023.29
| Facility | | $436.52 | $851.14 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $323.59 / $489.78
| Professional | | $173.78 | $323.59 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $478.63 / $812.83
| Facility | | $331.13 | $478.63 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $288.40 / $426.58
| Professional | | $194.98 | $288.40 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $870.96
| Facility | | $109.65 | $199.53 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $416.87 / $870.96 / $1,148.15
| Facility | 25 | $416.87 | $870.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $363.08 / $616.60
| Professional | | $208.93 | $363.08 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $234.42 / $380.19 / $630.96
| Professional | 25 | $234.42 | $380.19 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,412.54
| Facility | | $1,174.90 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $269.15 / $446.68
| Professional | | $123.03 | $269.15 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $89.13
| Professional | 25 | $79.43 | $89.13 | $89.13 |