- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $81.28 / $117.49
| Facility | | $63.10 | $81.28 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $97.72 / $239.88
| Professional | | $69.18 | $97.72 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Professional | 25 | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $83.18 / $112.20
| Professional | | $63.10 | $83.18 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $79.43 / $89.13
| Facility | | $70.79 | $79.43 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $131.83
| Professional | | $72.44 | $97.72 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $154.88
| Professional | | $64.57 | $91.20 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $102.33 / $162.18
| Facility | | $81.28 | $102.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $102.33 / $645.65
| Professional | | $74.13 | $102.33 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $162.18
| Facility | | $69.18 | $93.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $93.33 / $151.36
| Professional | | $70.79 | $93.33 | $151.36 |