- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $144.54 / $380.19
| Facility | | $64.57 | $144.54 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | 25 | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $398.11
| Professional | | $128.82 | $181.97 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $354.81
| Professional | 25 | $173.78 | $269.15 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $213.80
| Professional | | $128.82 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $316.23
| Professional | | $131.83 | $173.78 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $173.78 / $331.13
| Professional | | $64.57 | $173.78 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $190.55 / $263.03
| Facility | | $158.49 | $190.55 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Professional | | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $257.04
| Professional | | $120.23 | $165.96 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $147.91
| Facility | | $141.25 | $141.25 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $158.49 / $281.84
| Professional | | $117.49 | $158.49 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,548.82
| Professional | | $1,230.27 | $1,230.27 | $1,548.82 |