- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $208.93
| Facility | | $162.18 | $162.18 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $162.18 / $295.12
| Professional | | $125.89 | $162.18 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $331.13
| Professional | 25 | $114.82 | $181.97 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $154.88 / $165.96
| Professional | | $131.83 | $154.88 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $50.12 / $131.83 / $154.88
| Professional | 25 | $50.12 | $131.83 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $199.53
| Professional | | $147.91 | $147.91 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $213.80 / $288.40
| Facility | | $158.49 | $213.80 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $194.98 / $363.08
| Professional | | $158.49 | $194.98 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Facility | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $239.88
| Professional | | $213.80 | $213.80 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $251.19
| Professional | | $141.25 | $177.83 | $251.19 |