- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $3,019.95 / $4,168.69
| Facility | | $912.01 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $1,000.00 / $2,041.74 / $4,168.69
| Facility | 25 | $1,000.00 | $2,041.74 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $177.83 / $524.81
| Professional | | $117.49 | $177.83 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $158.49 / $338.84 / $794.33
| Professional | 25 | $158.49 | $338.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $141.25 / $169.82 / $223.87
| Professional | 25 | $141.25 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $338.84
| Professional | | $165.96 | $218.78 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $190.55 / $309.03
| Facility | | $165.96 | $190.55 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $389.05
| Professional | | $158.49 | $218.78 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $1,096.48 / $2,187.76
| Facility | | $269.15 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $3,235.94 / $3,801.89
| Facility | | $2,884.03 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $389.05
| Professional | | $131.83 | $186.21 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $89.13 / $389.05
| Professional | 25 | $60.26 | $89.13 | $389.05 |