- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $186.21 / $275.42
| Facility | | $87.10 | $186.21 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $354.81
| Professional | | $128.82 | $181.97 | $354.81 |
- 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
- $131.83 / $162.18 / $208.93
| Professional | | $131.83 | $162.18 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $229.09 / $263.03
| Facility | | $194.98 | $229.09 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $263.03
| Professional | | $199.53 | $245.47 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $218.78
| Facility | | $120.23 | $165.96 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $223.87 / $436.52
| Professional | | $181.97 | $223.87 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $151.36 / $346.74
| Professional | | $61.66 | $151.36 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $199.53 / $323.59
| Facility | | $87.10 | $199.53 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $302.00
| Professional | | $128.82 | $181.97 | $302.00 |
- 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
- $60.26 / $141.25 / $204.17
| Professional | | $60.26 | $141.25 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $501.19
| Facility | | $147.91 | $181.97 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $234.42
| Professional | | $114.82 | $158.49 | $234.42 |