- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $302.00
| Facility | | $141.25 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $128.82 / $275.42
| Professional | | $40.74 | $128.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $77.62 / $141.25 / $213.80
| Professional | 25 | $77.62 | $141.25 | $213.80 |
- 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
- $229.09 / $288.40 / $346.74
| Professional | | $229.09 | $288.40 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $269.15
| Facility | | $109.65 | $154.88 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $223.87 / $331.13
| Professional | | $117.49 | $223.87 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $44.67 / $141.25 / $213.80
| Professional | 25 | $44.67 | $141.25 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $218.78 / $257.04
| Facility | | $154.88 | $218.78 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $158.49 / $269.15
| Facility | | $107.15 | $158.49 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $131.83 / $131.83
| Professional | | $109.65 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $234.42 / $537.03
| Facility | | $199.53 | $234.42 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $269.15 / $354.81
| Professional | | $199.53 | $269.15 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $208.93 / $302.00
| Professional | | $117.49 | $208.93 | $302.00 |