- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $794.33 / $1,047.13
| Facility | | $104.71 | $794.33 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $338.84
| Professional | | $104.71 | $158.49 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $218.78 / $407.38
| Professional | 25 | $104.71 | $218.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $158.49 / $173.78
| Professional | | $131.83 | $158.49 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $154.88
| Professional | 25 | $131.83 | $131.83 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $190.55 / $213.80
| Facility | | $154.88 | $190.55 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $426.58
| Professional | | $109.65 | $165.96 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $363.08
| Facility | | $151.36 | $229.09 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $134.90 / $302.00
| Professional | | $93.33 | $134.90 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $204.17 / $275.42
| Professional | | $128.82 | $204.17 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $295.12
| Professional | | $112.20 | $173.78 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,348.96 / $1,348.96
| Professional | | $1,047.13 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $165.96 / $275.42
| Facility | | $112.20 | $165.96 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $416.87
| Professional | | $162.18 | $162.18 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $537.03
| Professional | | $407.38 | $407.38 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $151.36 / $295.12
| Professional | | $100.00 | $151.36 | $295.12 |