- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $2,398.83 / $2,454.71
| Facility | | $199.53 | $2,398.83 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | 25 | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $204.17 / $851.14
| Professional | | $91.20 | $204.17 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $109.65 / $426.58 / $1,862.09
| Professional | 25 | $109.65 | $426.58 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $109.65 / $190.55
| Professional | | $83.18 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $138.04 / $199.53
| Professional | 25 | $104.71 | $138.04 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $158.49
| Professional | | $81.28 | $104.71 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $251.19
| Professional | | $100.00 | $131.83 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $114.82 / $199.53
| Facility | | $89.13 | $114.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $1,174.90
| Professional | | $107.15 | $165.96 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $173.78 / $588.84 / $602.56
| Professional | 25 | $173.78 | $588.84 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $95.50
| Facility | | $87.10 | $87.10 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $218.78
| Professional | | $97.72 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $257.04
| Professional | 25 | $79.43 | $85.11 | $257.04 |