- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | 25 | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $812.83
| Professional | | $91.20 | $162.18 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $426.58 / $1,995.26
| Professional | 25 | $114.82 | $426.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $114.82 / $199.53
| Professional | | $83.18 | $114.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $177.83
| Professional | 25 | $97.72 | $134.90 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $199.53
| Professional | | $97.72 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $199.53
| Professional | | $97.72 | $128.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $173.78
| Facility | | $102.33 | $125.89 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $131.83 / $269.15
| Professional | | $112.20 | $131.83 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $134.90 / $245.47
| Professional | | $102.33 | $134.90 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $257.04
| Professional | | $102.33 | $138.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $61.66
| Professional | | $32.36 | $33.11 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $154.88 / $229.09
| Professional | | $104.71 | $154.88 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $213.80
| Professional | | $91.20 | $125.89 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $186.21
| Professional | 25 | $79.43 | $85.11 | $186.21 |