- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $79.43
| Facility | | $42.66 | $42.66 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $79.43 / $173.78
| Professional | | $40.74 | $79.43 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $75.86 / $173.78 / $186.21
| Professional | 25 | $75.86 | $173.78 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $91.20 / $199.53
| Professional | | $79.43 | $91.20 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $85.11 / $154.88
| Professional | | $45.71 | $85.11 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $79.43 / $181.97
| Professional | | $39.81 | $79.43 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $83.18 / $162.18
| Facility | | $43.65 | $83.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $309.03
| Professional | | $75.86 | $112.20 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | 25 | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $162.18 / $204.17
| Professional | | $95.50 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $204.17
| Professional | | $91.20 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $75.86 / $173.78
| Professional | | $40.74 | $75.86 | $173.78 |