- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $169.82
| Professional | | $58.88 | $75.86 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $186.21
| Professional | 25 | $60.26 | $79.43 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $79.43 / $134.90
| Professional | | $54.95 | $79.43 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $138.04
| Professional | 25 | $58.88 | $75.86 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $165.96
| Professional | | $74.13 | $107.15 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $95.50 / $162.18
| Professional | | $70.79 | $95.50 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $524.81
| Professional | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $66.07 / $123.03
| Facility | | $48.98 | $66.07 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $91.20 / $141.25
| Professional | | $67.61 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $70.79 / $95.50 / $100.00
| Professional | 25 | $70.79 | $95.50 | $100.00 |