- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $354.81
| Facility | | $95.50 | $154.88 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $61.66 / $288.40 / $660.69
| Facility | 25 | $61.66 | $288.40 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $398.11
| Professional | | $104.71 | $173.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $117.49 / $199.53 / $457.09
| Professional | 25 | $117.49 | $199.53 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $186.21
| Facility | | $134.90 | $165.96 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $269.15
| Professional | | $89.13 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | 25 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $263.03
| Facility | | $109.65 | $165.96 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $177.83 / $338.84
| Professional | | $125.89 | $177.83 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $131.83 / $208.93
| Facility | | $74.13 | $131.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $165.96 / $354.81
| Professional | | $83.18 | $165.96 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $131.83 / $309.03
| Professional | 25 | $79.43 | $131.83 | $309.03 |