- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $69.18
| Facility | | $64.57 | $64.57 | $69.18 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | 25 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $74.13 / $147.91
| Professional | | $57.54 | $74.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $60.26 / $100.00 / $194.98
| Professional | 25 | $60.26 | $100.00 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $87.10 / $120.23
| Facility | | $70.79 | $87.10 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $83.18 / $181.97
| Professional | | $77.62 | $83.18 | $181.97 |
- 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
- $69.18 / $91.20 / $380.19
| Professional | | $69.18 | $91.20 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $83.18 / $123.03
| Professional | | $72.44 | $83.18 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $67.61 / $75.86 / $117.49
| Professional | 25 | $67.61 | $75.86 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $89.13 / $134.90
| Professional | | $58.88 | $89.13 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $100.00
| Professional | 25 | $95.50 | $95.50 | $100.00 |