- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $125.89 / $162.18
| Facility | | $81.28 | $125.89 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $223.87
| Professional | | $72.44 | $100.00 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | 25 | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $112.20
| Professional | | $64.57 | $83.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | 25 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $69.18
| Facility | | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $93.33 / $131.83
| Professional | | $61.66 | $93.33 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $173.78
| Professional | | $95.50 | $123.03 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $162.18
| Professional | | $64.57 | $95.50 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $181.97
| Facility | | $87.10 | $104.71 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $107.15 / $575.44
| Professional | | $75.86 | $107.15 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $144.54 / $158.49
| Professional | | $69.18 | $144.54 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $75.86 / $131.83
| Facility | | $64.57 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $97.72 / $147.91
| Professional | | $70.79 | $97.72 | $147.91 |