- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $186.21
| Facility | | $123.03 | $154.88 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $165.96 / $295.12
| Professional | | $125.89 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Professional | 25 | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $194.98
| Professional | | $125.89 | $158.49 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $165.96 / $165.96
| Facility | | $154.88 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $245.47
| Professional | | $169.82 | $208.93 | $245.47 |
- 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
- $75.86 / $165.96 / $302.00
| Professional | | $75.86 | $165.96 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $229.09
| Facility | | $147.91 | $181.97 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $1,230.27
| Professional | | $134.90 | $194.98 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $141.25 / $158.49
| Facility | | $128.82 | $141.25 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $257.04
| Professional | | $125.89 | $173.78 | $257.04 |