- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $131.83 / $162.18
| Facility | | $104.71 | $131.83 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Facility | 25 | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $112.20 / $257.04
| Professional | | $79.43 | $112.20 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $354.81 / $645.65
| Facility | | $91.20 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $154.88 / $660.69
| Professional | | $97.72 | $154.88 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $251.19 / $346.74
| Facility | | $131.83 | $251.19 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $213.80 / $281.84
| Professional | | $131.83 | $213.80 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $263.03
| Professional | | $107.15 | $169.82 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $120.23 / $346.74
| Facility | | $63.10 | $120.23 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $109.65 / $181.97
| Professional | | $60.26 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $190.55 / $275.42
| Professional | | $109.65 | $190.55 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $977.24 / $1,698.24
| Facility | | $912.01 | $977.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $199.53 / $251.19
| Professional | | $125.89 | $199.53 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $354.81 / $645.65
| Facility | | $91.20 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $154.88 / $660.69
| Professional | | $97.72 | $154.88 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $109.65 / $194.98
| Professional | | $75.86 | $109.65 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $295.12
| Professional | | $104.71 | $169.82 | $295.12 |