- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $275.42 / $416.87
| Facility | | $251.19 | $275.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $309.03 / $645.65
| Professional | | $218.78 | $309.03 | $645.65 |
- 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
- $446.68 / $660.69 / $1,023.29
| Professional | | $446.68 | $660.69 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,023.29 / $2,454.71
| Facility | | $724.44 | $1,023.29 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $812.83 / $1,230.27
| Professional | | $489.78 | $812.83 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,000.00 / $1,949.84
| Facility | | $794.33 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $707.95 / $1,122.02
| Professional | | $489.78 | $707.95 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $457.09 / $794.33
| Facility | | $251.19 | $457.09 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $831.76
| Facility | 54 | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $549.54 / $1,905.46
| Professional | | $275.42 | $549.54 | $1,905.46 |
- 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
- $245.47 / $537.03 / $1,000.00
| Professional | | $245.47 | $537.03 | $1,000.00 |