- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $218.78
| Facility | | $75.86 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $102.33 / $229.09
| Professional | | $74.13 | $102.33 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $407.38
| Professional | 25 | $173.78 | $173.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $85.11 / $117.49
| Professional | | $63.10 | $85.11 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $100.00 / $186.21
| Professional | | $77.62 | $100.00 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $91.20 / $162.18
| Professional | | $63.10 | $91.20 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $162.18
| Facility | | $89.13 | $120.23 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $70.79 / $79.43
| Professional | | $60.26 | $70.79 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $95.50 / $144.54
| Professional | | $70.79 | $95.50 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $74.13
| Facility | | $70.79 | $70.79 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $95.50 / $162.18
| Professional | | $72.44 | $95.50 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $851.14
| Professional | | $645.65 | $645.65 | $851.14 |