- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $165.96
| Facility | | $109.65 | $109.65 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- 25
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Facility | 25 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $275.42
| Professional | | $104.71 | $151.36 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $346.74
| Professional | 25 | $104.71 | $104.71 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $218.78 / $416.87
| Facility | | $56.23 | $218.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $257.04 / $323.59
| Professional | | $218.78 | $257.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $302.00
| Facility | | $114.82 | $165.96 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $199.53 / $338.84
| Professional | | $123.03 | $199.53 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $346.74
| Professional | 25 | $104.71 | $104.71 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $33.11 / $323.59
| Professional | | $30.20 | $33.11 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $269.15 / $416.87
| Facility | | $151.36 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $208.93 / $309.03
| Professional | | $165.96 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $263.03
| Professional | | $120.23 | $165.96 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $190.55 / $288.40
| Professional | | $128.82 | $190.55 | $288.40 |