- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $125.89
| Facility | | $100.00 | $104.71 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $64.57 / $125.89
| Professional | | $56.23 | $64.57 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $64.57 / $69.18 / $245.47
| Professional | 25 | $64.57 | $69.18 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $69.18 / $93.33
| Professional | | $66.07 | $69.18 | $93.33 |
- 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
- $66.07 / $87.10 / $131.83
| Professional | | $66.07 | $87.10 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $102.33
| Professional | | $32.36 | $33.11 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $134.90
| Facility | | $57.54 | $79.43 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $102.33 / $190.55
| Professional | | $67.61 | $102.33 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $102.33 / $112.20
| Facility | | $93.33 | $102.33 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $104.71 / $147.91
| Professional | | $70.79 | $104.71 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | 25 | $93.33 | $93.33 | $93.33 |