- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $100.00 / $117.49
| Facility | | $87.10 | $100.00 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $186.21
| Professional | | $87.10 | $109.65 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | 25 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $123.03 / $1,819.70
| Facility | | $117.49 | $123.03 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $316.23 / $478.63
| Professional | | $190.55 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $380.19
| Professional | 25 | $154.88 | $251.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $331.13
| Facility | | $269.15 | $269.15 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $269.15 / $457.09
| Professional | | $186.21 | $269.15 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $263.03
| Facility | | $234.42 | $234.42 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $275.42 / $416.87
| Professional | | $186.21 | $275.42 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $169.82 / $575.44
| Facility | | $81.28 | $169.82 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $213.80 / $416.87
| Professional | | $114.82 | $213.80 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $269.15 / $446.68
| Professional | | $131.83 | $269.15 | $446.68 |