- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $251.19
| Professional | | $63.10 | $109.65 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $275.42
| Professional | 50 | $173.78 | $173.78 | $275.42 |
- 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
- $100.00 / $120.23 / $141.25
| Professional | | $100.00 | $120.23 | $141.25 |
- 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
- $66.07 / $91.20 / $141.25
| Professional | | $66.07 | $91.20 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $162.18
| Facility | | $104.71 | $144.54 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $162.18
| Professional | | $104.71 | $144.54 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $165.96
| Facility | | $69.18 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $169.82
| Professional | | $72.44 | $100.00 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $114.82 / $162.18
| Professional | | $79.43 | $114.82 | $162.18 |