- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $549.54 / $549.54
| Facility | | $165.96 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $162.18 / $323.59
| Professional | | $131.83 | $162.18 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | 25 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $263.03 / $269.15
| Facility | | $151.36 | $263.03 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $234.42 / $269.15
| Professional | | $158.49 | $234.42 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $251.19
| Professional | | $141.25 | $186.21 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $239.88 / $363.08
| Facility | | $154.88 | $239.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $1,047.13
| Professional | | $154.88 | $251.19 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $269.15 / $389.05
| Professional | | $239.88 | $269.15 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $380.19
| Professional | | $275.42 | $275.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $263.03 / $323.59
| Professional | | $190.55 | $263.03 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $239.88 / $363.08
| Professional | | $144.54 | $239.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $239.88 / $239.88
| Professional | | $199.53 | $239.88 | $239.88 |