- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $109.65 / $165.96
| Facility | | $107.15 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $123.03 / $229.09
| Professional | | $91.20 | $123.03 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $190.55
| Professional | 25 | $97.72 | $123.03 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | 52 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $112.20 / $128.82
| Professional | | $100.00 | $112.20 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $128.82
| Professional | 25 | $104.71 | $123.03 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $154.88
| Professional | | $117.49 | $117.49 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $223.87
| Facility | | $123.03 | $165.96 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $288.40
| Professional | | $123.03 | $154.88 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $239.88
| Professional | | $138.04 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $204.17
| Professional | 25 | $173.78 | $173.78 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $177.83
| Professional | | $97.72 | $123.03 | $177.83 |