- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $2,089.30 / $3,630.78
| Facility | | $239.88 | $2,089.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $707.95 / $912.01 / $1,621.81
| Facility | 25 | $707.95 | $912.01 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $309.03
| Professional | | $91.20 | $131.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $95.50 / $257.04 / $446.68
| Professional | 25 | $95.50 | $257.04 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $229.09
| Professional | | $109.65 | $162.18 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $229.09
| Professional | 25 | $112.20 | $169.82 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $524.81
| Facility | | $446.68 | $446.68 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $186.21 / $245.47
| Professional | | $107.15 | $186.21 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $223.87 / $295.12
| Professional | | $112.20 | $223.87 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $186.21 / $1,621.81
| Facility | | $107.15 | $186.21 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $912.01 / $1,445.44 / $1,905.46
| Facility | 25 | $912.01 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $302.00
| Professional | | $151.36 | $229.09 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $151.36 / $218.78 / $309.03
| Professional | 25 | $151.36 | $218.78 | $309.03 |
- 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
- $229.09 / $263.03 / $288.40
| Professional | | $229.09 | $263.03 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,290.87
| Facility | | $1,949.84 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $186.21 / $245.47
| Professional | | $162.18 | $186.21 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $186.21 / $288.40
| Professional | | $120.23 | $186.21 | $288.40 |