- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $1,096.48
| Facility | | $630.96 | $630.96 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $851.14 / $977.24 / $1,698.24
| Facility | 25 | $851.14 | $977.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $117.49 / $218.78
| Professional | | $89.13 | $117.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $371.54
| Professional | 25 | $95.50 | $154.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $208.93
| Professional | | $97.72 | $114.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $208.93
| Professional | 25 | $114.82 | $134.90 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $851.14
| Facility | | $467.74 | $588.84 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $123.03 / $165.96
| Professional | | $120.23 | $123.03 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $190.55
| Professional | | $107.15 | $134.90 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $316.23
| Facility | | $120.23 | $147.91 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $588.84
| Facility | 25 | $501.19 | $501.19 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $741.31
| Professional | | $104.71 | $144.54 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $144.54 / $407.38
| Professional | 25 | $114.82 | $144.54 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $165.96
| Professional | | $97.72 | $123.03 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $338.84
| Professional | 25 | $89.13 | $151.36 | $338.84 |