- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,000.00 / $2,187.76
| Facility | | $354.81 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $645.65 / $1,047.13 / $2,344.23
| Facility | 25 | $645.65 | $1,047.13 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $354.81
| Professional | | $89.13 | $120.23 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $223.87 / $537.03
| Professional | 25 | $97.72 | $223.87 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $263.03
| Professional | | $112.20 | $186.21 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $117.49 / $190.55 / $295.12
| Professional | 25 | $117.49 | $190.55 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $199.53 / $295.12
| Professional | | $138.04 | $199.53 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $295.12
| Professional | | $107.15 | $154.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $154.88 / $251.19
| Facility | | $117.49 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $114.82 / $295.12
| Professional | | $112.20 | $114.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $204.17 / $281.84
| Professional | | $123.03 | $204.17 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,691.53 / $3,801.89
| Facility | | $2,137.96 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $234.42
| Professional | | $97.72 | $128.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $173.78
| Professional | 25 | $79.43 | $89.13 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Professional | | $741.31 | $741.31 | $741.31 |