- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Facility | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $72.44 / $213.80
| Professional | | $56.23 | $72.44 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $64.57 / $120.23 / $208.93
| Professional | 25 | $64.57 | $120.23 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $446.68 / $446.68
| Facility | | $34.67 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $194.98
| Professional | | $64.57 | $95.50 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $186.21
| Facility | | $81.28 | $81.28 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $125.89 / $173.78
| Professional | | $81.28 | $125.89 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $100.00 / $186.21
| Professional | | $61.66 | $100.00 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $57.54 / $102.33
| Facility | | $32.36 | $57.54 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $67.61 / $128.82
| Professional | | $39.81 | $67.61 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $125.89 / $199.53
| Professional | | $75.86 | $125.89 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $446.68 / $446.68
| Facility | | $34.67 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $194.98
| Professional | | $64.57 | $95.50 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Facility | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $100.00 / $204.17
| Professional | | $66.07 | $100.00 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | 25 | $93.33 | $93.33 | $93.33 |