- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $177.83
| Facility | | $162.18 | $162.18 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $1,862.09
| Facility | 25 | $645.65 | $645.65 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $208.93 / $851.14
| Professional | | $91.20 | $208.93 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $173.78 / $616.60 / $1,862.09
| Professional | 25 | $173.78 | $616.60 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $229.09
| Professional | | $89.13 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $302.00
| Professional | 25 | $97.72 | $138.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $245.47
| Professional | | $109.65 | $154.88 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $165.96 / $3,630.78
| Facility | | $100.00 | $165.96 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $141.25 / $229.09
| Professional | | $104.71 | $141.25 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $102.33
| Facility | | $93.33 | $93.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $204.17
| Professional | | $97.72 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $75.86 / $87.10 / $234.42
| Professional | 25 | $75.86 | $87.10 | $234.42 |