- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $1,288.25 / $3,715.35
| Facility | | $338.84 | $1,288.25 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | 50 | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $199.53 / $416.87
| Professional | | $81.28 | $199.53 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | 50 | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,230.27 / $1,949.84
| Facility | | $398.11 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $346.74
| Professional | | $89.13 | $147.91 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $524.81 / $524.81
| Facility | | $39.81 | $524.81 | $524.81 |
- 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
- $89.13 / $181.97 / $346.74
| Professional | | $89.13 | $181.97 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $1,096.48 / $2,454.71
| Facility | | $338.84 | $1,096.48 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $169.82 / $338.84
| Professional | | $74.13 | $169.82 | $338.84 |