- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $6,760.83
| Facility | | $125.89 | $138.04 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | 25 | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $158.49 / $776.25
| Professional | | $91.20 | $158.49 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $158.49 / $588.84 / $1,621.81
| Professional | 25 | $158.49 | $588.84 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $109.65 / $177.83
| Professional | | $97.72 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $257.04
| Professional | 25 | $97.72 | $120.23 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $117.49 / $158.49
| Professional | | $107.15 | $117.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $208.93
| Facility | | $100.00 | $138.04 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $269.15
| Professional | | $112.20 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $134.90 / $204.17
| Professional | | $100.00 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $154.88 / $165.96
| Professional | | $131.83 | $154.88 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $125.89 / $154.88 / $426.58
| Professional | 25 | $125.89 | $154.88 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $177.83
| Professional | | $97.72 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $144.54
| Professional | 25 | $79.43 | $79.43 | $144.54 |