- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,513.56 / $2,570.40
| Facility | | $398.11 | $1,513.56 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $1,318.26 / $1,380.38 / $1,621.81
| Facility | 25 | $1,318.26 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $263.03 / $812.83
| Professional | | $173.78 | $263.03 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $190.55 / $371.54 / $1,023.29
| Professional | 25 | $190.55 | $371.54 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $398.11
| Professional | | $177.83 | $208.93 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $512.86
| Professional | 25 | $173.78 | $213.80 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $204.17 / $323.59
| Professional | | $177.83 | $204.17 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $275.42 / $537.03
| Professional | | $204.17 | $275.42 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $245.47 / $446.68
| Facility | | $177.83 | $245.47 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $389.05 / $1,737.80
| Professional | | $239.88 | $389.05 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $245.47 / $1,148.15 / $1,230.27
| Professional | 25 | $245.47 | $1,148.15 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $2,137.96
| Facility | | $173.78 | $213.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $269.15 / $489.78
| Professional | | $194.98 | $269.15 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $85.11 / $251.19 / $398.11
| Professional | 25 | $85.11 | $251.19 | $398.11 |