- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $41.69 / $134.90
| Facility | | $41.69 | $41.69 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $141.25 / $229.09
| Professional | | $63.10 | $141.25 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $91.20 / $177.83 / $331.13
| Professional | 25 | $91.20 | $177.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $213.80 / $239.88
| Professional | | $131.83 | $213.80 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $194.98 / $331.13
| Professional | | $81.28 | $194.98 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $257.04
| Facility | | $79.43 | $141.25 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $190.55 / $389.05
| Professional | | $120.23 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $223.87 / $275.42 / $302.00
| Professional | 25 | $223.87 | $275.42 | $302.00 |
- 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
- $131.83 / $181.97 / $288.40
| Professional | | $131.83 | $181.97 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $128.82 / $251.19
| Professional | | $64.57 | $128.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $331.13
| Professional | | $169.82 | $208.93 | $331.13 |