- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $630.96 / $2,041.74
| Facility | | $134.90 | $630.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- 50
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | 50 | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $467.74
| Professional | | $114.82 | $165.96 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $158.49 / $389.05 / $630.96
| Professional | 50 | $158.49 | $389.05 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $371.54
| Facility | | $269.15 | $269.15 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $154.88 / $204.17
| Professional | | $125.89 | $154.88 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $177.83 / $269.15
| Professional | | $112.20 | $177.83 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $251.19
| Professional | | $125.89 | $125.89 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $346.74 / $380.19 / $416.87
| Professional | 50 | $346.74 | $380.19 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $446.68 / $891.25
| Facility | | $128.82 | $446.68 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $263.03
| Professional | | $104.71 | $147.91 | $263.03 |