- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $154.88 / $281.84
| Facility | | $100.00 | $154.88 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $147.91 / $316.23
| Professional | | $100.00 | $147.91 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $199.53 / $218.78 / $446.68
| Professional | 25 | $199.53 | $218.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $165.96
| Professional | | $95.50 | $123.03 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $275.42
| Professional | | $107.15 | $147.91 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $125.89 / $239.88
| Professional | | $70.79 | $125.89 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $223.87
| Facility | | $128.82 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $120.23 / $120.23
| Professional | | $60.26 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $199.53
| Professional | | $104.71 | $128.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $109.65
| Facility | | $104.71 | $104.71 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $138.04 / $245.47
| Professional | | $104.71 | $138.04 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,258.93
| Professional | | $977.24 | $977.24 | $1,258.93 |