- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $181.97
| Facility | | $138.04 | $138.04 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $173.78
| Professional | | $57.54 | $72.44 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $58.88 / $79.43 / $158.49
| Professional | 25 | $58.88 | $79.43 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $85.11 / $186.21
| Professional | | $57.54 | $85.11 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $63.10 / $77.62 / $144.54
| Professional | 25 | $63.10 | $77.62 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $269.15 / $363.08
| Facility | | $107.15 | $269.15 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $117.49 / $158.49
| Professional | | $69.18 | $117.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $138.04 / $213.80
| Professional | | $70.79 | $138.04 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $95.50 / $151.36
| Facility | | $63.10 | $95.50 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $151.36 / $524.81
| Professional | | $81.28 | $151.36 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | 25 | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $199.53
| Professional | | $120.23 | $151.36 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $151.36 / $199.53
| Professional | | $123.03 | $151.36 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $208.93
| Professional | | $117.49 | $117.49 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.09 / $0.09 / $123.03
| Facility | | $0.09 | $0.09 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $194.98
| Professional | | $79.43 | $125.89 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $100.00
| Professional | 25 | $83.18 | $83.18 | $100.00 |