- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $173.78 / $194.98
| Facility | | $75.86 | $173.78 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $77.62 / $204.17
| Professional | | $60.26 | $77.62 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $67.61 / $83.18 / $295.12
| Professional | 25 | $67.61 | $83.18 | $295.12 |
- 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
- $79.43 / $144.54 / $218.78
| Professional | | $79.43 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $158.49 / $204.17
| Professional | | $120.23 | $158.49 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $162.18
| Facility | | $64.57 | $95.50 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $144.54 / $208.93
| Professional | | $77.62 | $144.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $67.61 / $83.18 / $263.03
| Professional | 25 | $67.61 | $83.18 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $162.18 / $165.96
| Facility | | $102.33 | $162.18 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $97.72 / $165.96
| Facility | | $64.57 | $97.72 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $162.18 / $208.93
| Professional | | $81.28 | $162.18 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $269.15 / $323.59
| Facility | | $223.87 | $269.15 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $223.87
| Professional | | $123.03 | $162.18 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $380.19
| Facility | | $123.03 | $123.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $144.54 / $208.93
| Professional | | $83.18 | $144.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Professional | 25 | $100.00 | $100.00 | $100.00 |