- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $954.99 / $1,819.70
| Facility | | $630.96 | $954.99 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $741.31 / $933.25 / $2,187.76
| Facility | 25 | $741.31 | $933.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $346.74
| Professional | | $81.28 | $120.23 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $213.80 / $457.09
| Professional | 25 | $97.72 | $213.80 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $123.03 / $208.93
| Professional | | $100.00 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $208.93
| Professional | 25 | $97.72 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $131.83 / $204.17
| Professional | | $104.71 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $134.90 / $169.82
| Professional | | $117.49 | $134.90 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $257.04
| Professional | | $107.15 | $151.36 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $263.03
| Facility | | $95.50 | $151.36 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $281.84 / $512.86 / $912.01
| Facility | 25 | $281.84 | $512.86 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $741.31
| Professional | | $109.65 | $162.18 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $302.00
| Professional | 25 | $141.25 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $302.00
| Professional | | $169.82 | $199.53 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | 25 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,187.76 / $3,235.94
| Facility | | $1,445.44 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $229.09
| Professional | | $91.20 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $338.84
| Professional | 25 | $79.43 | $89.13 | $338.84 |