- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $97.72
| Facility | | $87.10 | $87.10 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $269.15
| Professional | | $87.10 | $109.65 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $229.09 / $891.25
| Professional | 25 | $100.00 | $229.09 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $177.83
| Professional | | $97.72 | $120.23 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $181.97
| Professional | 25 | $97.72 | $134.90 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $660.69 / $1,096.48
| Facility | | $467.74 | $660.69 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $117.49 / $162.18
| Professional | | $107.15 | $117.49 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $131.83 / $204.17
| Professional | | $102.33 | $131.83 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $229.09
| Facility | | $87.10 | $117.49 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $1,174.90
| Professional | | $107.15 | $147.91 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $251.19
| Facility | | $109.65 | $125.89 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $120.23 / $165.96
| Professional | | $95.50 | $120.23 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $144.54
| Professional | 25 | $79.43 | $89.13 | $144.54 |