- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $1,621.81 / $5,623.41
| Facility | | $131.83 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $144.54 / $338.84
| Professional | | $79.43 | $144.54 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | 50 | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,071.52 / $1,698.24
| Facility | | $831.76 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $263.03
| Professional | | $109.65 | $165.96 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $269.15
| Professional | | $104.71 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $239.88 / $457.09
| Professional | | $117.49 | $239.88 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $117.49 / $208.93
| Professional | | $112.20 | $117.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $2,089.30 / $4,365.16
| Facility | | $630.96 | $2,089.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $162.18 / $281.84
| Professional | | $95.50 | $162.18 | $281.84 |