- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $131.83
| Facility | | $77.62 | $77.62 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $354.81
| Facility | 25 | $229.09 | $229.09 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $125.89 / $234.42
| Professional | | $89.13 | $125.89 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $239.88
| Professional | 25 | $97.72 | $134.90 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $125.89
| Professional | | $95.50 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $125.89
| Professional | 25 | $104.71 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $141.25
| Facility | | $125.89 | $125.89 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $87.10 / $112.20
| Professional | | $83.18 | $87.10 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $134.90
| Facility | | $128.82 | $128.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $151.36
| Professional | | $109.65 | $109.65 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $114.82 / $173.78
| Professional | | $87.10 | $114.82 | $173.78 |