- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $1,148.15
| Facility | | $208.93 | $275.42 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | 25 | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $147.91 / $794.33
| Professional | | $91.20 | $147.91 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $363.08 / $2,238.72
| Professional | 25 | $114.82 | $363.08 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $190.55 / $229.09
| Professional | | $112.20 | $190.55 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $177.83 / $204.17
| Professional | 25 | $93.33 | $177.83 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $691.83
| Facility | | $588.84 | $588.84 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $169.82 / $229.09
| Professional | | $100.00 | $169.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $371.54
| Professional | | $104.71 | $190.55 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $144.54 / $204.17
| Facility | | $91.20 | $144.54 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $223.87 / $1,174.90
| Professional | | $141.25 | $223.87 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $169.82 / $186.21 / $281.84
| Professional | 25 | $169.82 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $288.40
| Professional | | $173.78 | $213.80 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $223.87 / $281.84
| Professional | | $190.55 | $223.87 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,754.23
| Facility | | $2,398.83 | $2,398.83 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $194.98 / $295.12
| Professional | | $107.15 | $194.98 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.12 / $0.12 / $0.12
| Facility | | $0.12 | $0.12 | $0.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $281.84
| Professional | | $120.23 | $173.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | 25 | $79.43 | $79.43 | $79.43 |