- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $213.80 / $275.42
| Facility | | $131.83 | $213.80 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $154.88 / $363.08
| Professional | | $112.20 | $154.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | 25 | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | 52 | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $169.82
| Professional | | $102.33 | $125.89 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $204.17
| Professional | | $79.43 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $186.21 / $263.03
| Professional | | $144.54 | $186.21 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $269.15
| Professional | | $95.50 | $151.36 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $309.03
| Facility | | $141.25 | $173.78 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $954.99
| Professional | | $117.49 | $173.78 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $208.93 / $245.47
| Professional | | $181.97 | $208.93 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $125.89 / $204.17
| Facility | | $75.86 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $239.88
| Professional | | $104.71 | $151.36 | $239.88 |