- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,905.46 / $3,162.28
| Facility | | $645.65 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $741.31 / $1,698.24 / $3,162.28
| Facility | 25 | $741.31 | $1,698.24 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $338.84
| Professional | | $81.28 | $120.23 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $234.42 / $575.44
| Professional | 25 | $100.00 | $234.42 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $141.25 / $281.84
| Professional | | $100.00 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $245.47
| Professional | 25 | $100.00 | $131.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $229.09
| Professional | | $107.15 | $141.25 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $151.36 / $194.98
| Professional | | $117.49 | $151.36 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $131.83 / $213.80
| Facility | | $114.82 | $131.83 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $138.04 / $275.42
| Professional | | $114.82 | $138.04 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $263.03
| Professional | | $107.15 | $147.91 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $831.76 / $1,778.28
| Facility | | $186.21 | $831.76 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $186.21 / $398.11
| Professional | | $107.15 | $186.21 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $69.18
| Professional | | $32.36 | $33.11 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $281.84
| Professional | | $104.71 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $154.88 / $245.47
| Professional | | $117.49 | $154.88 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,511.89 / $2,884.03
| Facility | | $2,344.23 | $2,511.89 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $275.42
| Professional | | $91.20 | $131.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $85.11 / $89.13 / $158.49
| Professional | 25 | $85.11 | $89.13 | $158.49 |