- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $141.25 / $208.93
| Facility | | $87.10 | $141.25 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $251.19
| Facility | 25 | $177.83 | $177.83 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $66.07 / $144.54
| Professional | | $38.02 | $66.07 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $47.86 / $93.33 / $177.83
| Professional | 25 | $47.86 | $93.33 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $81.28 / $194.98
| Professional | | $47.86 | $81.28 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $81.28 / $151.36
| Facility | | $44.67 | $81.28 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $251.19
| Facility | 25 | $177.83 | $177.83 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $102.33 / $239.88
| Professional | | $48.98 | $102.33 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $50.12 / $100.00 / $204.17
| Professional | 25 | $50.12 | $100.00 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $3,467.37
| Facility | | $114.82 | $114.82 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $213.80
| Professional | | $114.82 | $169.82 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $79.43 / $147.91
| Facility | | $44.67 | $79.43 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $102.33 / $190.55
| Professional | | $58.88 | $102.33 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $89.13 / $218.78
| Professional | | $41.69 | $89.13 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $173.78
| Professional | 25 | $70.79 | $70.79 | $173.78 |