- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $1,621.81 / $4,897.79
| Facility | | $501.19 | $1,621.81 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $588.84 / $1,000.00 / $4,897.79
| Facility | 25 | $588.84 | $1,000.00 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $426.58
| Professional | | $123.03 | $162.18 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $169.82 / $537.03 / $794.33
| Professional | 25 | $169.82 | $537.03 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $165.96 / $467.74 / $676.08
| Professional | 25 | $165.96 | $467.74 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,818.38 / $3,388.44
| Facility | | $1,737.80 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $208.93 / $354.81
| Professional | | $147.91 | $208.93 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $5,011.87 / $5,623.41
| Facility | | $4,466.84 | $5,011.87 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $199.53 / $323.59
| Professional | | $141.25 | $199.53 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $169.82 / $295.12
| Professional | | $1.86 | $169.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Professional | 25 | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $5,128.61 / $6,456.54
| Facility | | $5,128.61 | $5,128.61 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $194.98 / $331.13
| Professional | | $138.04 | $194.98 | $331.13 |