- 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
- $52.48 / $64.57 / $158.49
| Professional | | $52.48 | $64.57 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $58.88 / $109.65 / $138.04
| Professional | 25 | $58.88 | $109.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $128.82 / $162.18
| Professional | | $60.26 | $128.82 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $87.10 / $144.54
| Facility | | $52.48 | $87.10 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $112.20 / $457.09
| Professional | | $66.07 | $112.20 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $144.54
| Professional | | $102.33 | $141.25 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $158.49
| Professional | | $112.20 | $112.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $114.82 / $154.88
| Professional | | $83.18 | $114.82 | $154.88 |
- 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
- $64.57 / $91.20 / $151.36
| Professional | | $64.57 | $91.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $102.33 / $104.71
| Professional | | $85.11 | $102.33 | $104.71 |