- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $263.03 / $269.15
| Facility | | $239.88 | $263.03 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $251.19
| Professional | | $97.72 | $123.03 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $2.63 / $120.23 / $128.82
| Professional | 25 | $2.63 | $120.23 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $223.87
| Professional | | $104.71 | $128.82 | $223.87 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $120.23 / $123.03
| Professional | | $114.82 | $120.23 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $281.84
| Professional | | $109.65 | $154.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $257.04
| Facility | | $117.49 | $169.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $194.98 / $812.83
| Professional | | $112.20 | $194.98 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $186.21 / $302.00
| Professional | | $162.18 | $186.21 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $199.53 / $302.00
| Professional | | $141.25 | $199.53 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $218.78 / $331.13
| Professional | | $120.23 | $218.78 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.12 / $0.12 / $0.12
| Facility | | $0.12 | $0.12 | $0.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $302.00
| Professional | | $117.49 | $181.97 | $302.00 |