- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $831.76 / $1,659.59
| Facility | | $251.19 | $831.76 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $575.44 / $954.99 / $2,187.76
| Facility | 25 | $575.44 | $954.99 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $125.89 / $776.25
| Professional | | $87.10 | $125.89 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $199.53 / $257.04 / $776.25
| Professional | 25 | $199.53 | $257.04 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $213.80
| Facility | | $117.49 | $138.04 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $281.84
| Professional | | $114.82 | $134.90 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $562.34
| Professional | | $109.65 | $162.18 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | 25 | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $162.18 / $245.47
| Professional | | $134.90 | $162.18 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $144.54 / $158.49 / $245.47
| Professional | 25 | $144.54 | $158.49 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $275.42
| Professional | | $81.28 | $120.23 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $173.78
| Professional | 25 | $79.43 | $79.43 | $173.78 |