- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $181.97 / $263.03
| Facility | | $95.50 | $181.97 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $154.88
| Professional | | $58.88 | $77.62 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $83.18 / $173.78
| Professional | 25 | $60.26 | $83.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $72.44 / $85.11
| Professional | | $58.88 | $72.44 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $54.95 / $66.07 / $85.11
| Professional | 25 | $54.95 | $66.07 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $85.11 / $165.96
| Professional | | $77.62 | $85.11 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $114.82
| Facility | | $100.00 | $100.00 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $173.78
| Professional | | $63.10 | $104.71 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $181.97
| Professional | | $100.00 | $120.23 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $257.04 / $467.74
| Facility | | $186.21 | $257.04 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $93.33 / $162.18
| Professional | | $79.43 | $93.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $89.13 / $158.49
| Professional | | $57.54 | $89.13 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $83.18 / $95.50 / $100.00
| Professional | 25 | $83.18 | $95.50 | $100.00 |