- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $794.33 / $2,041.74
| Facility | | $323.59 | $794.33 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $416.87 / $776.25
| Professional | | $288.40 | $416.87 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,380.38
| Professional | 50 | $1,047.13 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $223.87 / $645.65 / $1,000.00
| Professional | 54 | $223.87 | $645.65 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $288.40
| Facility | | $208.93 | $208.93 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $371.54 / $489.78
| Professional | | $354.81 | $371.54 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $1,122.02
| Facility | | $426.58 | $426.58 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $416.87 / $562.34
| Professional | | $275.42 | $416.87 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $398.11 / $741.31
| Facility | | $128.82 | $398.11 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $346.74 / $616.60
| Professional | | $263.03 | $346.74 | $616.60 |