- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $112.20 / $239.88
| Facility | | $81.28 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $177.83
| Professional | | $60.26 | $79.43 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $77.62 / $181.97
| Professional | 25 | $60.26 | $77.62 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $83.18 / $134.90
| Professional | | $53.70 | $83.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $134.90
| Professional | 25 | $64.57 | $83.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $128.82 / $199.53
| Professional | | $79.43 | $128.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $104.71 / $186.21
| Professional | | $69.18 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $141.25
| Facility | | $64.57 | $85.11 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $467.74
| Professional | | $208.93 | $208.93 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $120.23 / $181.97
| Professional | | $69.18 | $120.23 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $123.03
| Facility | | $95.50 | $95.50 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $91.20 / $147.91
| Professional | | $67.61 | $91.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $95.50 / $100.00
| Professional | 25 | $79.43 | $95.50 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $524.81
| Professional | | $524.81 | $524.81 | $524.81 |