- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $70.79 / $208.93
| Professional | | $56.23 | $70.79 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $56.23 / $181.97 / $245.47
| Professional | 25 | $56.23 | $181.97 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $120.23 / $194.98
| Professional | | $64.57 | $120.23 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $104.71 / $229.09
| Professional | | $66.07 | $104.71 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $67.61 / $134.90
| Facility | | $54.95 | $67.61 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $114.82 / $457.09
| Professional | | $72.44 | $114.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $173.78
| Professional | | $102.33 | $138.04 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $144.54 / $194.98
| Professional | | $131.83 | $144.54 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $117.49 / $169.82
| Professional | | $66.07 | $117.49 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $91.20 / $112.20
| Facility | | $74.13 | $91.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $91.20 / $151.36
| Professional | | $69.18 | $91.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | 25 | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $100.00 / $102.33
| Professional | | $79.43 | $100.00 | $102.33 |