- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $257.04 / $257.04
| Facility | | $165.96 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $162.18 / $331.13
| Professional | | $114.82 | $162.18 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $257.04
| Professional | 25 | $114.82 | $114.82 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $302.00 / $331.13
| Facility | | $208.93 | $302.00 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $323.59
| Professional | | $245.47 | $309.03 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $346.74
| Facility | | $141.25 | $190.55 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $229.09 / $380.19
| Professional | | $134.90 | $229.09 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $257.04
| Professional | 25 | $114.82 | $114.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $33.11 / $323.59
| Professional | | $30.20 | $33.11 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $245.47 / $251.19
| Facility | | $208.93 | $245.47 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $239.88 / $380.19
| Professional | | $194.98 | $239.88 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $169.82 / $234.42
| Professional | | $151.36 | $169.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $338.84
| Professional | | $154.88 | $229.09 | $338.84 |