- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $1,584.89
| Facility | 25 | $954.99 | $954.99 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $269.15
| Professional | | $125.89 | $158.49 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $162.18 / $288.40 / $1,047.13
| Professional | 25 | $162.18 | $288.40 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $302.00
| Professional | 25 | $138.04 | $165.96 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $851.14
| Facility | | $467.74 | $588.84 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $204.17 / $275.42
| Professional | | $165.96 | $204.17 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $457.09
| Facility | | $177.83 | $223.87 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $1,023.29
| Facility | 25 | $645.65 | $645.65 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $776.25
| Professional | 25 | $208.93 | $275.42 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $245.47
| Professional | | $141.25 | $177.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $75.86 / $89.13 / $416.87
| Professional | 25 | $75.86 | $89.13 | $416.87 |