- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $141.25
| Facility | | $89.13 | $89.13 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $141.25 / $323.59
| Professional | | $87.10 | $141.25 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $331.13
| Professional | 25 | $316.23 | $316.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $281.84 / $354.81
| Professional | | $190.55 | $281.84 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $295.12
| Professional | 25 | $186.21 | $186.21 | $295.12 |
- 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
- $93.33 / $173.78 / $275.42
| Professional | | $93.33 | $173.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $131.83 / $323.59
| Professional | | $69.18 | $131.83 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $158.49 / $295.12
| Facility | | $91.20 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $275.42 / $371.54
| Professional | | $134.90 | $275.42 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $151.36 / $288.40 / $354.81
| Professional | 25 | $151.36 | $288.40 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $295.12 / $363.08
| Professional | | $194.98 | $295.12 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $269.15 / $363.08
| Professional | | $186.21 | $269.15 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $134.90 / $309.03
| Professional | | $61.66 | $134.90 | $309.03 |