- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $162.18 / $190.55
| Facility | | $128.82 | $162.18 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $144.54 / $331.13
| Professional | | $89.13 | $144.54 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Professional | 25 | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $446.68
| Professional | | $112.20 | $169.82 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $234.42 / $269.15
| Facility | | $186.21 | $234.42 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $186.21 / $363.08
| Professional | | $134.90 | $186.21 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $125.89 / $288.40
| Professional | | $72.44 | $125.89 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $199.53
| Facility | | $91.20 | $151.36 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $147.91 / $199.53
| Professional | | $128.82 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $208.93 / $389.05
| Professional | | $128.82 | $208.93 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $120.23 / $158.49
| Facility | | $91.20 | $120.23 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $120.23 / $158.49
| Professional | | $91.20 | $120.23 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $446.68
| Professional | | $112.20 | $169.82 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $199.53
| Professional | | $107.15 | $114.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $151.36 / $177.83
| Facility | | $131.83 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $158.49 / $380.19
| Professional | | $100.00 | $158.49 | $380.19 |