- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $75.86 / $95.50
| Facility | | $64.57 | $75.86 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $91.20 / $162.18
| Professional | | $70.79 | $91.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Professional | 25 | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $83.18 / $109.65
| Professional | | $63.10 | $83.18 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $100.00 / $100.00
| Facility | | $95.50 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $138.04
| Professional | | $95.50 | $114.82 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $89.13 / $151.36
| Professional | | $64.57 | $89.13 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $125.89
| Facility | | $83.18 | $100.00 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $109.65 / $645.65
| Professional | | $75.86 | $109.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $72.44 / $81.28
| Facility | | $70.79 | $72.44 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $100.00 / $144.54
| Professional | | $70.79 | $100.00 | $144.54 |