- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $213.80
| Facility | | $165.96 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $72.44 / $173.78
| Professional | | $38.90 | $72.44 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $72.44 / $75.86 / $204.17
| Professional | 50 | $72.44 | $75.86 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46,773.51 / $75,857.76 / $95,499.26
| Facility | | $46,773.51 | $75,857.76 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $77.62 / $91.20
| Professional | | $60.26 | $77.62 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Facility | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $63.10 / $91.20
| Professional | | $47.86 | $63.10 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $91.20 / $104.71
| Facility | | $66.07 | $91.20 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $91.20 / $104.71
| Professional | | $66.07 | $91.20 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $67.61 / $104.71
| Facility | | $45.71 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $79.43 / $112.20
| Professional | | $53.70 | $79.43 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $75.86 / $104.71
| Professional | | $53.70 | $75.86 | $104.71 |