- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $154.88
| Professional | | $57.54 | $70.79 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $208.93
| Professional | 25 | $51.29 | $79.43 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $89.13 / $141.25
| Professional | | $66.07 | $89.13 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $77.62 / $141.25
| Professional | | $74.13 | $77.62 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $109.65
| Facility | | $87.10 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $147.91
| Professional | | $64.57 | $87.10 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $120.23
| Professional | | $64.57 | $85.11 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $125.89
| Facility | | $60.26 | $79.43 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $141.25
| Facility | | $69.18 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $141.25
| Professional | | $69.18 | $83.18 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $102.33
| Facility | | $53.70 | $67.61 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $131.83
| Professional | | $57.54 | $83.18 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | 25 | $93.33 | $93.33 | $93.33 |