- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $120.23 / $323.59
| Facility | | $93.33 | $120.23 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $309.03
| Professional | | $100.00 | $138.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Professional | 25 | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $165.96
| Professional | | $93.33 | $123.03 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $120.23 / $134.90
| Facility | | $107.15 | $120.23 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $177.83
| Professional | | $97.72 | $128.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $128.82 / $234.42
| Professional | | $74.13 | $128.82 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $239.88
| Facility | | $120.23 | $147.91 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $954.99
| Professional | | $109.65 | $147.91 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $239.88
| Facility | | $100.00 | $138.04 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $213.80
| Professional | | $100.00 | $131.83 | $213.80 |