- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $2,041.74 / $4,073.80
| Facility | | $562.34 | $2,041.74 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $5,128.61
| Facility | 25 | $1,905.46 | $1,905.46 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $128.82 / $630.96
| Professional | | $89.13 | $128.82 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $120.23 / $269.15 / $1,000.00
| Professional | 25 | $120.23 | $269.15 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $158.49 / $363.08
| Professional | | $97.72 | $158.49 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $295.12
| Facility | | $102.33 | $158.49 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $5,128.61
| Facility | 25 | $1,905.46 | $1,905.46 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $331.13 / $645.65
| Professional | | $123.03 | $331.13 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $120.23 / $416.87 / $1,318.26
| Professional | 25 | $120.23 | $416.87 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $295.12 / $398.11
| Professional | | $263.03 | $295.12 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $154.88 / $269.15
| Facility | | $97.72 | $154.88 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $199.53 / $331.13
| Professional | | $95.50 | $199.53 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $169.82 / $436.52
| Professional | | $100.00 | $169.82 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $257.04
| Professional | 25 | $79.43 | $79.43 | $257.04 |