- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $234.42
| Facility | | $128.82 | $165.96 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $302.00
| Professional | | $107.15 | $141.25 | $302.00 |
- 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
- $104.71 / $204.17 / $213.80
| Facility | | $104.71 | $204.17 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $275.42
| Professional | | $169.82 | $199.53 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $234.42
| Professional | | $141.25 | $186.21 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $194.98 / $363.08
| Facility | | $123.03 | $194.98 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $263.03 / $1,047.13
| Professional | | $125.89 | $263.03 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $239.88 / $389.05
| Professional | | $190.55 | $239.88 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $218.78 / $371.54
| Professional | | $169.82 | $218.78 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $239.88 / $323.59
| Professional | | $162.18 | $239.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $199.53 / $338.84
| Professional | | $114.82 | $199.53 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $229.09 / $295.12
| Professional | | $223.87 | $229.09 | $295.12 |