- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $109.65 / $208.93
| Facility | | $97.72 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $316.23
| Professional | | $109.65 | $151.36 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | 25 | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Professional | 52 | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $186.21
| Professional | | $97.72 | $128.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $223.87
| Professional | | $112.20 | $151.36 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $234.42
| Facility | | $109.65 | $165.96 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $218.78 / $257.04
| Professional | | $162.18 | $218.78 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $144.54 / $239.88
| Professional | | $89.13 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $245.47
| Professional | | $141.25 | $177.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $77.62 / $91.20 / $162.18
| Professional | 52 | $77.62 | $91.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $275.42
| Professional | | $107.15 | $169.82 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Facility | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $295.12
| Professional | | $109.65 | $158.49 | $295.12 |