- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $154.88
| Facility | | $97.72 | $125.89 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $346.74
| Professional | | $109.65 | $151.36 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | 25 | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $173.78
| Professional | | $95.50 | $128.82 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $141.25
| Facility | | $112.20 | $125.89 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $218.78
| Professional | | $128.82 | $169.82 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $251.19
| Professional | | $97.72 | $147.91 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $162.18 / $269.15
| Facility | | $128.82 | $162.18 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $1,096.48
| Professional | | $123.03 | $173.78 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $257.04
| Facility | | $109.65 | $162.18 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $147.91 / $234.42
| Professional | | $102.33 | $147.91 | $234.42 |