- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $131.83 / $190.55
| Facility | | $95.50 | $131.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $234.42
| Professional | | $85.11 | $125.89 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $138.04 / $213.80
| Professional | 25 | $77.62 | $138.04 | $213.80 |
- 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
- $120.23 / $128.82 / $194.98
| Professional | | $120.23 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $125.89
| Professional | 25 | $100.00 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $218.78
| Professional | | $194.98 | $194.98 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $213.80
| Facility | | $123.03 | $162.18 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $154.88 / $194.98
| Professional | | $120.23 | $154.88 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $181.97
| Professional | | $109.65 | $109.65 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $128.82 / $190.55
| Facility | | $107.15 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $234.42
| Professional | | $95.50 | $128.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $138.04 / $218.78
| Professional | 25 | $77.62 | $138.04 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $125.89
| Professional | | $109.65 | $109.65 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $151.36
| Facility | | $93.33 | $123.03 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $218.78
| Professional | | $97.72 | $128.82 | $218.78 |