- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $162.18
| Facility | | $131.83 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $67.61 / $162.18
| Professional | | $56.23 | $67.61 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $56.23 / $112.20 / $138.04
| Professional | 25 | $56.23 | $112.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $269.15 / $363.08
| Facility | | $147.91 | $269.15 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $144.54
| Professional | | $63.10 | $104.71 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $128.82 / $190.55
| Professional | | $66.07 | $128.82 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $87.10 / $134.90
| Facility | | $57.54 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $141.25 / $457.09
| Professional | | $70.79 | $141.25 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $173.78
| Professional | | $102.33 | $141.25 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $138.04 / $173.78
| Professional | | $114.82 | $138.04 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $181.97
| Professional | | $102.33 | $102.33 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.08 / $0.08 / $112.20
| Facility | | $0.08 | $0.08 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $112.20 / $169.82
| Professional | | $74.13 | $112.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | 25 | $93.33 | $93.33 | $93.33 |