- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $107.15 / $295.12
| Facility | | $104.71 | $107.15 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $257.04
| Professional | | $97.72 | $128.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $245.47
| Professional | 25 | $107.15 | $141.25 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $144.54 / $812.83
| Facility | | $112.20 | $144.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $380.19
| Professional | | $109.65 | $162.18 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $177.83
| Professional | 25 | $60.26 | $87.10 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $141.25
| Professional | | $109.65 | $109.65 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $181.97 / $251.19
| Facility | | $120.23 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $181.97 / $263.03
| Professional | | $131.83 | $181.97 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $251.19 / $371.54
| Professional | | $141.25 | $251.19 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $134.90 / $144.54
| Professional | | $117.49 | $134.90 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $144.54 / $812.83
| Facility | | $112.20 | $144.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $380.19
| Professional | | $109.65 | $162.18 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $177.83
| Professional | 25 | $60.26 | $87.10 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $117.49 / $251.19
| Facility | | $22.91 | $117.49 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $295.12
| Professional | | $138.04 | $204.17 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $138.04
| Facility | | $107.15 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $371.54
| Professional | | $109.65 | $181.97 | $371.54 |