- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $134.90 / $288.40
| Facility | | $69.18 | $134.90 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | 25 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $107.15 / $257.04
| Professional | | $64.57 | $107.15 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $74.13 / $128.82 / $275.42
| Professional | 25 | $74.13 | $128.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $114.82 / $165.96
| Professional | | $81.28 | $114.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $234.42
| Professional | 25 | $100.00 | $120.23 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $602.56 / $602.56
| Facility | | $173.78 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $208.93
| Professional | | $117.49 | $162.18 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $173.78 / $199.53
| Facility | | $151.36 | $173.78 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $134.90 / $218.78
| Professional | | $89.13 | $134.90 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $269.15
| Professional | | $87.10 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $208.93 / $269.15
| Professional | | $112.20 | $208.93 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $93.33
| Facility | | $69.18 | $69.18 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $147.91 / $275.42
| Professional | | $87.10 | $147.91 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $89.13 / $131.83 / $141.25
| Professional | 25 | $89.13 | $131.83 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $79.43 / $120.23
| Facility | | $72.44 | $79.43 | $120.23 |