- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $371.54
| Facility | | $112.20 | $125.89 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $117.49 / $147.91 / $436.52
| Facility | 25 | $117.49 | $147.91 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $144.54 / $316.23
| Professional | | $77.62 | $144.54 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $363.08
| Professional | 25 | $131.83 | $186.21 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | 50 | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $134.90 / $288.40
| Professional | | $81.28 | $134.90 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $389.05
| Facility | | $104.71 | $151.36 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $138.04 / $295.12
| Professional | | $77.62 | $138.04 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $95.50 / $151.36
| Facility | | $72.44 | $95.50 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $104.71 / $204.17
| Professional | | $57.54 | $104.71 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Professional | 25 | $64.57 | $64.57 | $64.57 |