- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $204.17 / $281.84
| Facility | | $131.83 | $204.17 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $389.05
| Professional | | $128.82 | $181.97 | $389.05 |
- 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
- $128.82 / $158.49 / $204.17
| Professional | | $128.82 | $158.49 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $141.25 / $234.42
| Professional | | $85.11 | $141.25 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $316.23
| Professional | | $165.96 | $218.78 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $177.83 / $309.03
| Professional | | $75.86 | $177.83 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $194.98 / $346.74
| Facility | | $158.49 | $194.98 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $194.98 / $1,230.27
| Professional | | $125.89 | $194.98 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $288.40
| Professional | | $208.93 | $251.19 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $234.42
| Facility | | $75.86 | $128.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $269.15
| Professional | | $109.65 | $165.96 | $269.15 |