- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $371.54 / $891.25
| Facility | | $323.59 | $371.54 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $363.08 / $707.95
| Professional | | $295.12 | $363.08 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $812.83 / $2,290.87
| Facility | | $323.59 | $812.83 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $851.14 / $1,348.96
| Professional | | $562.34 | $851.14 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,348.96 / $3,235.94
| Facility | | $954.99 | $1,348.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,047.13 / $1,621.81
| Professional | | $630.96 | $1,047.13 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,318.26 / $2,570.40
| Facility | | $1,047.13 | $1,318.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $933.25 / $1,479.11
| Professional | | $616.60 | $933.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $562.34 / $1,000.00
| Facility | | $316.23 | $562.34 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | 54 | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $691.83 / $2,398.83
| Professional | | $354.81 | $691.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,778.28 / $3,715.35
| Facility | | $616.60 | $1,778.28 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $660.69 / $1,230.27
| Professional | | $323.59 | $660.69 | $1,230.27 |