- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $165.96 / $380.19
| Facility | | $91.20 | $165.96 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $316.23
| Professional | | $107.15 | $154.88 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $524.81 / $676.08 / $676.08
| Professional | 25 | $524.81 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | 52 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $128.82 / $169.82
| Professional | | $102.33 | $128.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $165.96 / $269.15
| Professional | | $112.20 | $165.96 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $177.83 / $257.04
| Professional | | $138.04 | $177.83 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $190.55
| Facility | | $107.15 | $141.25 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $229.09
| Professional | | $134.90 | $165.96 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $269.15
| Professional | | $102.33 | $151.36 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $263.03
| Professional | | $107.15 | $147.91 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $109.65
| Professional | | $32.36 | $33.11 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $302.00
| Professional | | $109.65 | $162.18 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $269.15
| Professional | | $138.04 | $190.55 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $275.42
| Professional | | $95.50 | $154.88 | $275.42 |