- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,000.00 / $2,137.96
| Facility | | $398.11 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $549.54 / $954.99 / $2,691.53
| Facility | 25 | $549.54 | $954.99 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $177.83 / $478.63
| Professional | | $117.49 | $177.83 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $162.18 / $323.59 / $691.83
| Professional | 25 | $162.18 | $323.59 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $147.91 / $177.83 / $257.04
| Professional | 25 | $147.91 | $177.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $199.53 / $295.12
| Professional | | $154.88 | $199.53 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $371.54
| Professional | | $158.49 | $218.78 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $389.05
| Facility | | $138.04 | $218.78 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $199.53 / $524.81 / $1,698.24
| Facility | 25 | $199.53 | $524.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $199.53 / $251.19 / $323.59
| Professional | 25 | $199.53 | $251.19 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,311.31 / $4,265.80
| Facility | | $1,949.84 | $3,311.31 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $323.59
| Professional | | $131.83 | $186.21 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $245.47
| Professional | 25 | $79.43 | $89.13 | $245.47 |