- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $295.12 / $812.83
| Facility | | $114.82 | $295.12 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $537.03 / $794.33 / $812.83
| Facility | 25 | $537.03 | $794.33 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $194.98 / $812.83
| Professional | | $91.20 | $194.98 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $138.04 / $562.34 / $1,348.96
| Professional | 25 | $138.04 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $190.55
| Professional | | $97.72 | $138.04 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $177.83
| Professional | 25 | $91.20 | $107.15 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $97.72 / $131.83
| Professional | | $91.20 | $97.72 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $4,265.80 / $4,786.30
| Facility | | $165.96 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $131.83 / $234.42
| Professional | | $102.33 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $151.36 / $162.18
| Professional | | $138.04 | $151.36 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $223.87
| Facility | | $95.50 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $181.97
| Professional | | $95.50 | $114.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $257.04
| Professional | 25 | $79.43 | $89.13 | $257.04 |