- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $891.25 / $1,737.80
| Facility | | $81.28 | $891.25 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | 50 | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $97.72 / $199.53
| Professional | | $53.70 | $97.72 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $83.18 / $213.80 / $389.05
| Professional | 50 | $83.18 | $213.80 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | 50 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $707.95 / $954.99
| Facility | | $602.56 | $707.95 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $891.25 / $1,071.52 / $1,445.44
| Facility | 50 | $891.25 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $109.65
| Professional | | $58.88 | $75.86 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $100.00 / $218.78
| Professional | | $52.48 | $100.00 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $549.54 / $1,348.96
| Facility | | $239.88 | $549.54 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $72.44 / $173.78
| Professional | | $44.67 | $72.44 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | 50 | $85.11 | $85.11 | $85.11 |