- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $112.20 / $112.20
| Facility | | $52.48 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $112.20 / $239.88
| Professional | | $52.48 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $173.78
| Professional | 50 | $123.03 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,621.81 / $3,388.44
| Facility | | $912.01 | $1,621.81 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $1,621.81 / $2,630.27 / $7,413.10
| Facility | 50 | $1,621.81 | $2,630.27 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $194.98 / $398.11
| Professional | | $97.72 | $194.98 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $147.91 / $295.12 / $588.84
| Professional | 50 | $147.91 | $295.12 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $416.87 / $1,000.00
| Facility | | $295.12 | $416.87 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $229.09 / $467.74
| Professional | | $117.49 | $229.09 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $389.05 / $776.25
| Facility | | $316.23 | $389.05 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $213.80 / $380.19
| Professional | | $117.49 | $213.80 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $147.91 / $794.33
| Facility | | $74.13 | $147.91 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $229.09 / $537.03
| Professional | | $112.20 | $229.09 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $239.88 / $245.47 / $295.12
| Professional | 50 | $239.88 | $245.47 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $2,238.72 / $5,370.32
| Facility | | $1,174.90 | $2,238.72 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $165.96 / $346.74
| Professional | | $79.43 | $165.96 | $346.74 |