- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $4,897.79 / $4,897.79
| Facility | | $831.76 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $588.84
| Professional | | $87.10 | $117.49 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $398.11 / $1,348.96
| Professional | 25 | $114.82 | $398.11 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $323.59
| Professional | | $89.13 | $120.23 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $91.20 / $109.65 / $371.54
| Professional | 25 | $91.20 | $109.65 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,818.38 / $3,388.44
| Facility | | $1,737.80 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $141.25 / $223.87
| Professional | | $104.71 | $141.25 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $4,897.79 / $5,370.32
| Facility | | $4,897.79 | $4,897.79 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $134.90 / $208.93
| Professional | | $95.50 | $134.90 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.05 / $123.03 / $186.21
| Professional | | $1.05 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Professional | 25 | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.05 / $147.91 / $199.53
| Professional | | $1.05 | $147.91 | $199.53 |
- 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
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $128.82 / $223.87
| Professional | | $93.33 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $234.42
| Professional | 25 | $79.43 | $120.23 | $234.42 |