- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $380.19
| Professional | | $134.90 | $177.83 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $416.87
| Professional | 25 | $134.90 | $208.93 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $1,047.13
| Facility | | $165.96 | $213.80 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $229.09 / $512.86
| Professional | | $158.49 | $229.09 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $109.65 / $223.87
| Professional | 25 | $77.62 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $323.59 / $416.87
| Professional | | $194.98 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $190.55
| Professional | | $141.25 | $141.25 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $338.84
| Facility | | $151.36 | $229.09 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $234.42 / $346.74
| Professional | | $165.96 | $234.42 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $316.23 / $478.63
| Professional | | $177.83 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $1,047.13
| Facility | | $165.96 | $213.80 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $229.09 / $512.86
| Professional | | $158.49 | $229.09 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $109.65 / $223.87
| Professional | 25 | $77.62 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $263.03 / $338.84
| Professional | | $173.78 | $263.03 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $173.78 / $173.78
| Facility | | $158.49 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $478.63
| Professional | | $162.18 | $251.19 | $478.63 |