- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $177.83
| Facility | | $109.65 | $125.89 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $6.17 / $6.17 / $6.17
| Facility | 25 | $6.17 | $6.17 | $6.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $128.82 / $251.19
| Professional | | $70.79 | $128.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $91.20 / $144.54 / $239.88
| Professional | 25 | $91.20 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $131.83 / $263.03
| Professional | | $95.50 | $131.83 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $323.59
| Professional | | $165.96 | $218.78 | $323.59 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $158.49 / $323.59
| Facility | | $100.00 | $158.49 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $151.36 / $275.42
| Professional | | $97.72 | $151.36 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $70.79
| Professional | | $32.36 | $33.11 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $218.78 / $257.04
| Facility | | $154.88 | $218.78 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $257.04 / $436.52
| Facility | | $208.93 | $257.04 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $218.78 / $316.23
| Professional | | $162.18 | $218.78 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $138.04 / $151.36
| Facility | | $72.44 | $138.04 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $281.84
| Professional | | $114.82 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $154.88 / $295.12
| Professional | | $141.25 | $154.88 | $295.12 |