- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $389.05
| Professional | | $117.49 | $173.78 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $218.78 / $371.54 / $954.99
| Professional | 50 | $218.78 | $371.54 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46,773.51 / $75,857.76 / $95,499.26
| Facility | | $46,773.51 | $75,857.76 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $218.78
| Professional | | $162.18 | $190.55 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $186.21 / $218.78
| Professional | | $144.54 | $186.21 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $234.42 / $295.12
| Facility | | $204.17 | $234.42 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $234.42 / $295.12
| Professional | | $204.17 | $234.42 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $302.00
| Facility | | $141.25 | $204.17 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $186.21 / $275.42
| Professional | | $79.43 | $186.21 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $208.93 / $275.42
| Professional | | $151.36 | $208.93 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | 50 | $79.43 | $79.43 | $79.43 |