- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $1,621.81 / $5,248.07
| Facility | | $537.03 | $1,621.81 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $575.44 / $3,311.31 / $5,248.07
| Facility | 25 | $575.44 | $3,311.31 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $177.83 / $446.68
| Professional | | $128.82 | $177.83 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $141.25 / $389.05 / $616.60
| Professional | 25 | $141.25 | $389.05 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $190.55 / $257.04 / $338.84
| Professional | 25 | $190.55 | $257.04 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $776.25
| Facility | | $660.69 | $660.69 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $331.13 / $436.52
| Professional | | $165.96 | $331.13 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $263.03 / $1,819.70
| Facility | | $154.88 | $263.03 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $602.56 / $2,089.30 / $3,388.44
| Facility | 25 | $602.56 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $223.87 / $323.59 / $407.38
| Professional | 25 | $223.87 | $323.59 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $331.13 / $436.52
| Professional | | $251.19 | $331.13 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $275.42 / $426.58
| Professional | | $162.18 | $275.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | 25 | $79.43 | $79.43 | $79.43 |