- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $158.49 / $208.93
| Facility | | $123.03 | $158.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $245.47
| Professional | | $107.15 | $151.36 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $63.10 / $169.82 / $331.13
| Professional | 25 | $63.10 | $169.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $154.88
| Professional | 25 | $131.83 | $131.83 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $158.49
| Facility | | $114.82 | $114.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $147.91 / $199.53
| Professional | | $117.49 | $147.91 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $199.53
| Facility | | $169.82 | $169.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $162.18 / $162.18
| Professional | | $120.23 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $173.78
| Facility | | $162.18 | $162.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $213.80
| Professional | | $107.15 | $151.36 | $213.80 |