- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $1,288.25 / $3,715.35
| Facility | | $144.54 | $1,288.25 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Facility | 50 | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $93.33 / $173.78
| Professional | | $57.54 | $93.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $223.87 / $389.05 / $416.87
| Professional | 50 | $223.87 | $389.05 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $660.69 / $1,445.44
| Facility | | $354.81 | $660.69 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $100.00 / $151.36
| Professional | | $67.61 | $100.00 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $691.83 / $691.83
| Facility | | $39.81 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $107.15 / $199.53
| Professional | | $67.61 | $107.15 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $1,096.48 / $2,238.72
| Facility | | $338.84 | $1,096.48 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $190.55
| Professional | | $56.23 | $97.72 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Professional | 50 | $229.09 | $229.09 | $229.09 |