- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $104.71 / $138.04
| Facility | | $70.79 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $138.04 / $275.42
| Professional | | $89.13 | $138.04 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $123.03 / $123.03
| Professional | 25 | $79.43 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $169.82
| Professional | | $95.50 | $123.03 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $138.04 / $169.82
| Professional | | $131.83 | $138.04 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $234.42 / $234.42
| Facility | | $117.49 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $131.83 / $229.09
| Professional | | $79.43 | $131.83 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $117.49 / $151.36
| Professional | | $60.26 | $117.49 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $128.82 / $239.88
| Professional | | $32.36 | $128.82 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $114.82
| Facility | | $87.10 | $109.65 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $218.78
| Professional | | $91.20 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $123.03 / $165.96
| Professional | | $107.15 | $123.03 | $165.96 |