- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $162.18 / $223.87
| Facility | | $131.83 | $162.18 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | 25 | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $158.49 / $281.84
| Professional | | $112.20 | $158.49 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $398.11
| Professional | 25 | $104.71 | $190.55 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $302.00
| Professional | | $281.84 | $281.84 | $302.00 |
- 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
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $204.17 / $371.54
| Professional | | $123.03 | $204.17 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $181.97
| Professional | | $162.18 | $162.18 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $165.96
| Professional | | $128.82 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $269.15
| Facility | | $117.49 | $162.18 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $407.38
| Professional | | $144.54 | $144.54 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $363.08
| Professional | | $120.23 | $213.80 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $251.19
| Professional | | $102.33 | $151.36 | $251.19 |
- 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 / $1,047.13 / $1,348.96
| Professional | | $1,047.13 | $1,047.13 | $1,348.96 |