- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $891.25 / $2,137.96
| Facility | | $223.87 | $891.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $416.87 / $912.01 / $2,041.74
| Facility | 25 | $416.87 | $912.01 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $117.49 / $407.38
| Professional | | $81.28 | $117.49 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $95.50 / $173.78 / $549.54
| Professional | 25 | $95.50 | $173.78 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $208.93 / $302.00
| Professional | | $109.65 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $467.74
| Professional | | $114.82 | $181.97 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $177.83 / $323.59
| Facility | | $107.15 | $177.83 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $891.25
| Facility | 25 | $316.23 | $316.23 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $213.80 / $741.31
| Professional | | $123.03 | $213.80 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $288.40
| Professional | 25 | $177.83 | $239.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $295.12
| Professional | | $173.78 | $223.87 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $323.59 / $616.60
| Professional | | $165.96 | $323.59 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $3,235.94
| Facility | | $1,202.26 | $1,202.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $218.78 / $281.84
| Professional | | $123.03 | $218.78 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,691.53 / $2,691.53
| Facility | | $2,344.23 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $173.78 / $302.00
| Professional | | $109.65 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $173.78
| Professional | 25 | $79.43 | $85.11 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $199.53
| Professional | | $169.82 | $199.53 | $199.53 |