- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $302.00
| Facility | | $97.72 | $141.25 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $17.78 / $229.09 / $288.40
| Facility | 25 | $17.78 | $229.09 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $109.65 / $269.15
| Professional | | $66.07 | $109.65 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $144.54 / $181.97
| Professional | | $102.33 | $144.54 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $251.19
| Professional | | $120.23 | $165.96 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $134.90 / $223.87
| Professional | | $100.00 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $213.80
| Facility | | $100.00 | $131.83 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $263.03
| Professional | | $75.86 | $75.86 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $181.97 / $239.88
| Professional | | $107.15 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $208.93
| Professional | | $89.13 | $120.23 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |