- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $177.83
| Facility | | $123.03 | $154.88 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $199.53
| Professional | | $97.72 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $45.71 / $123.03 / $194.98
| Professional | 25 | $45.71 | $123.03 | $194.98 |
- 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 / $104.71 / $123.03
| Professional | | $100.00 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | 25 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $190.55
| Professional | | $162.18 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $245.47
| Facility | | $109.65 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $812.83
| Professional | | $107.15 | $141.25 | $812.83 |
- 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
- $104.71 / $131.83 / $190.55
| Professional | | $104.71 | $131.83 | $190.55 |