- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $165.96 / $323.59
| Professional | | $131.83 | $165.96 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $154.88 / $245.47 / $331.13
| Professional | 25 | $154.88 | $245.47 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $131.83 / $302.00
| Professional | | $1.00 | $131.83 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $165.96 / $204.17
| Professional | | $54.95 | $165.96 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Facility | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $169.82
| Professional | | $141.25 | $141.25 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $263.03 / $263.03
| Professional | | $245.47 | $263.03 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $309.03
| Facility | | $141.25 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $181.97
| Professional | | $32.36 | $33.11 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $257.04
| Professional | | $138.04 | $169.82 | $257.04 |