- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $1,737.80 / $7,413.10
| Facility | | $87.10 | $1,737.80 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $380.19 / $1,174.90 / $3,715.35
| Facility | 50 | $380.19 | $1,174.90 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $97.72 / $251.19
| Professional | | $52.48 | $97.72 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $97.72 / $194.98 / $575.44
| Professional | 50 | $97.72 | $194.98 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $3,715.35 / $9,549.93
| Facility | | $1,513.56 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $83.18 / $162.18
| Professional | | $52.48 | $83.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $239.88
| Professional | 50 | $79.43 | $125.89 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $204.17 / $549.54
| Facility | | $51.29 | $204.17 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $107.15 / $208.93
| Professional | | $61.66 | $107.15 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $1,023.29 / $3,311.31
| Facility | | $245.47 | $1,023.29 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $89.13 / $165.96
| Professional | | $52.48 | $89.13 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | 50 | $85.11 | $85.11 | $85.11 |