- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $1,288.25 / $3,715.35
| Facility | | $208.93 | $1,288.25 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | 50 | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $147.91 / $309.03
| Professional | | $100.00 | $147.91 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $165.96 / $302.00 / $602.56
| Professional | 50 | $165.96 | $302.00 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $223.87
| Professional | 50 | $177.83 | $177.83 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $562.34 / $977.24
| Facility | | $309.03 | $562.34 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $158.49 / $223.87
| Professional | | $117.49 | $158.49 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $363.08 / $363.08
| Facility | | $39.81 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $234.42
| Professional | | $117.49 | $169.82 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $501.19 / $1,258.93
| Facility | | $223.87 | $501.19 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $245.47
| Professional | | $97.72 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | 50 | $79.43 | $79.43 | $79.43 |