- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $69.18
| Facility | | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $72.44 / $223.87
| Professional | | $56.23 | $72.44 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $58.88 / $125.89 / $245.47
| Professional | 25 | $58.88 | $125.89 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $63.10 / $81.28
| Professional | | $54.95 | $63.10 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Professional | 25 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $26.30 / $128.82
| Facility | | $19.05 | $26.30 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $33.88 / $53.70
| Professional | | $25.70 | $33.88 | $53.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $89.13 / $165.96
| Professional | | $61.66 | $89.13 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $67.61 / $123.03
| Facility | | $54.95 | $67.61 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $93.33 / $457.09
| Professional | | $64.57 | $93.33 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $57.54 / $81.28
| Facility | | $50.12 | $57.54 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $77.62 / $131.83
| Professional | | $63.10 | $77.62 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | 25 | $93.33 | $93.33 | $93.33 |