- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $125.89 / $213.80
| Professional | | $42.66 | $125.89 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $213.80
| Professional | 25 | $100.00 | $138.04 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $104.71 / $123.03
| Professional | | $25.12 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $141.25
| Professional | 25 | $104.71 | $123.03 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $602.56 / $977.24
| Facility | | $354.81 | $602.56 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $120.23 / $169.82
| Professional | | $93.33 | $120.23 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $186.21
| Professional | | $32.36 | $33.11 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $144.54 / $234.42
| Facility | | $107.15 | $144.54 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $131.83
| Professional | | $109.65 | $109.65 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $154.88
| Facility | | $138.04 | $138.04 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $234.42
| Professional | | $112.20 | $162.18 | $234.42 |