- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $245.47 / $691.83
| Facility | | $147.91 | $245.47 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $131.83 / $724.44 / $870.96
| Facility | 25 | $131.83 | $724.44 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $812.83
| Professional | | $91.20 | $162.18 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $109.65 / $436.52 / $1,995.26
| Professional | 25 | $109.65 | $436.52 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $204.17 / $309.03
| Professional | | $109.65 | $204.17 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $251.19 / $316.23
| Professional | | $190.55 | $251.19 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $245.47
| Facility | | $97.72 | $147.91 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $131.83 / $724.44 / $1,000.00
| Facility | 25 | $131.83 | $724.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $218.78 / $331.13
| Professional | | $141.25 | $218.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $109.65 / $363.08 / $1,258.93
| Professional | 25 | $109.65 | $363.08 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $234.42 / $234.42
| Facility | | $141.25 | $234.42 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $245.47
| Facility | | $97.72 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $234.42 / $302.00
| Professional | | $97.72 | $234.42 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $245.47 / $323.59
| Professional | | $186.21 | $245.47 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $323.59
| Professional | | $120.23 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $186.21
| Professional | 25 | $79.43 | $79.43 | $186.21 |