- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $229.09
| Facility | | $141.25 | $181.97 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $269.15
| Professional | | $109.65 | $158.49 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $131.83 / $190.55 / $407.38
| Professional | 25 | $131.83 | $190.55 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $190.55 / $309.03
| Professional | | $131.83 | $190.55 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $288.40
| Professional | | $134.90 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $169.82
| Professional | | $128.82 | $158.49 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $275.42
| Facility | | $114.82 | $169.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $144.54
| Professional | | $87.10 | $102.33 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $234.42
| Facility | | $104.71 | $134.90 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $177.83 / $309.03
| Professional | | $107.15 | $177.83 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $812.83
| Facility | | $93.33 | $117.49 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $151.36 / $263.03
| Professional | | $97.72 | $151.36 | $263.03 |