- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $173.78 / $234.42
| Facility | | $144.54 | $173.78 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $141.25 / $302.00
| Professional | | $100.00 | $141.25 | $302.00 |
- 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
- $95.50 / $123.03 / $162.18
| Professional | | $95.50 | $123.03 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $199.53
| Professional | | $95.50 | $138.04 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $269.15
| Professional | | $141.25 | $181.97 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $138.04 / $239.88
| Professional | | $75.86 | $138.04 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $263.03
| Facility | | $125.89 | $151.36 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $851.14
| Professional | | $109.65 | $154.88 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $204.17 / $251.19
| Professional | | $173.78 | $204.17 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $194.98
| Facility | | $75.86 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $218.78
| Professional | | $95.50 | $141.25 | $218.78 |