- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $204.17 / $251.19
| Facility | | $134.90 | $204.17 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $123.03 / $229.09
| Professional | | $39.81 | $123.03 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $134.90 / $204.17
| Professional | 25 | $77.62 | $134.90 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $218.78
| Facility | | $162.18 | $204.17 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $239.88 / $257.04
| Professional | | $186.21 | $239.88 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $245.47
| Facility | | $107.15 | $141.25 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $144.54 / $275.42
| Professional | | $77.62 | $144.54 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $128.82 / $208.93
| Professional | 25 | $77.62 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $33.11 / $257.04
| Professional | | $30.20 | $33.11 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $194.98 / $194.98
| Facility | | $162.18 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $181.97 / $295.12
| Professional | | $154.88 | $181.97 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $131.83 / $169.82
| Professional | | $117.49 | $131.83 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $229.09
| Professional | | $104.71 | $158.49 | $229.09 |