- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $154.88
| Facility | | $123.03 | $123.03 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $309.03
| Professional | | $107.15 | $151.36 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Professional | 25 | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $123.03 / $154.88
| Professional | | $117.49 | $123.03 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $331.13
| Professional | | $162.18 | $204.17 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $186.21 / $302.00
| Facility | | $123.03 | $186.21 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $275.42 / $1,047.13
| Professional | | $144.54 | $275.42 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $263.03 / $389.05
| Professional | | $204.17 | $263.03 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $389.05
| Professional | | $204.17 | $288.40 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $316.23 / $426.58
| Professional | | $131.83 | $316.23 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.17 / $0.17 / $0.17
| Facility | | $0.17 | $0.17 | $0.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $204.17 / $354.81
| Professional | | $128.82 | $204.17 | $354.81 |