- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $114.82 / $165.96
| Facility | | $93.33 | $114.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $354.81
| Professional | | $117.49 | $169.82 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $223.87 / $354.81
| Professional | 25 | $104.71 | $223.87 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $158.49 / $213.80
| Professional | | $123.03 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $213.80
| Professional | | $162.18 | $169.82 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $281.84 / $281.84
| Facility | | $263.03 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $323.59
| Professional | | $109.65 | $181.97 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $144.54 / $186.21
| Professional | | $109.65 | $144.54 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $154.88 / $288.40
| Professional | | $32.36 | $154.88 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $147.91 / $154.88
| Facility | | $79.43 | $147.91 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $269.15
| Professional | | $102.33 | $158.49 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $147.91 / $204.17
| Professional | | $125.89 | $147.91 | $204.17 |