- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $70.79 / $165.96
| Professional | | $56.23 | $70.79 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $56.23 / $112.20 / $204.17
| Professional | 25 | $56.23 | $112.20 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $436.52 / $1,047.13
| Facility | | $131.83 | $436.52 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $223.87
| Professional | | $104.71 | $173.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $83.18 / $141.25 / $177.83
| Professional | 25 | $83.18 | $141.25 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $630.96
| Facility | | $151.36 | $229.09 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $162.18 / $275.42
| Professional | | $93.33 | $162.18 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $489.78
| Facility | | $162.18 | $251.19 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $162.18 / $239.88
| Professional | | $107.15 | $162.18 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $93.33 / $194.98
| Facility | | $57.54 | $93.33 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $138.04 / $446.68
| Professional | | $72.44 | $138.04 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $239.88
| Professional | 25 | $158.49 | $158.49 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $120.23 / $218.78
| Professional | | $70.79 | $120.23 | $218.78 |