- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $275.42 / $275.42
| Facility | | $128.82 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $257.04
| Professional | | $97.72 | $123.03 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $120.23 / $128.82
| Professional | 25 | $104.71 | $120.23 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $208.93 / $213.80
| Facility | | $123.03 | $208.93 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $181.97 / $213.80
| Professional | | $123.03 | $181.97 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $144.54 / $186.21
| Professional | | $109.65 | $144.54 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $162.18 / $281.84
| Facility | | $114.82 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $812.83
| Professional | | $102.33 | $165.96 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $190.55 / $302.00
| Professional | | $181.97 | $190.55 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $257.04
| Professional | | $181.97 | $181.97 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $251.19
| Professional | | $141.25 | $190.55 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $162.18 / $288.40
| Professional | | $100.00 | $162.18 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $190.55 / $190.55
| Professional | | $158.49 | $190.55 | $190.55 |