- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $239.88
| Facility | | $109.65 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $323.59
| Professional | | $112.20 | $162.18 | $323.59 |
- 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
- $102.33 / $128.82 / $173.78
| Professional | | $102.33 | $128.82 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $234.42
| Facility | | $173.78 | $181.97 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $177.83 / $234.42
| Professional | | $147.91 | $177.83 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $190.55
| Facility | | $104.71 | $144.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $199.53 / $389.05
| Professional | | $162.18 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $128.82 / $208.93
| Professional | | $66.07 | $128.82 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $275.42
| Facility | | $128.82 | $169.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $257.04
| Professional | | $117.49 | $162.18 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $123.03 / $173.78
| Professional | | $64.57 | $123.03 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $181.97 / $501.19
| Facility | | $120.23 | $181.97 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $213.80
| Professional | | $104.71 | $147.91 | $213.80 |