- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $177.83
| Facility | | $134.90 | $165.96 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $190.55
| Professional | | $57.54 | $72.44 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $12.30 / $245.47 / $457.09
| Professional | 25 | $12.30 | $245.47 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $131.83 / $194.98
| Professional | | $70.79 | $131.83 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $186.21
| Professional | | $114.82 | $151.36 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $89.13 / $144.54
| Facility | | $58.88 | $89.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $138.04 / $190.55
| Professional | | $85.11 | $138.04 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $12.30 / $245.47 / $457.09
| Professional | 25 | $12.30 | $245.47 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $141.25 / $141.25
| Facility | | $89.13 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $89.13 / $147.91
| Facility | | $60.26 | $89.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $144.54 / $190.55
| Professional | | $79.43 | $144.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $199.53
| Professional | | $114.82 | $147.91 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $186.21
| Professional | | $75.86 | $128.82 | $186.21 |