- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Facility | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $181.97 / $501.19
| Professional | | $87.10 | $181.97 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $1,174.90
| Professional | 50 | $269.15 | $269.15 | $1,174.90 |
- 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
- $117.49 / $117.49 / $316.23
| Professional | | $117.49 | $117.49 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $117.49 / $316.23
| Professional | | $114.82 | $117.49 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $295.12 / $380.19
| Facility | | $128.82 | $295.12 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $295.12 / $380.19
| Professional | | $128.82 | $295.12 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $229.09 / $346.74
| Facility | | $117.49 | $229.09 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $117.49 / $323.59
| Professional | | $79.43 | $117.49 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Facility | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $239.88 / $398.11
| Professional | | $123.03 | $239.88 | $398.11 |