- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $346.74 / $380.19
| Facility | | $309.03 | $346.74 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $338.84 / $870.96
| Professional | | $275.42 | $338.84 | $870.96 |
- 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
- $524.81 / $812.83 / $1,258.93
| Professional | | $524.81 | $812.83 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,258.93 / $3,019.95
| Facility | | $891.25 | $1,258.93 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $977.24 / $1,513.56
| Professional | | $602.56 | $977.24 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,230.27 / $2,398.83
| Facility | | $977.24 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $870.96 / $1,380.38
| Professional | | $575.44 | $870.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $549.54 / $977.24
| Facility | | $295.12 | $549.54 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | 54 | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $645.65 / $2,290.87
| Professional | | $338.84 | $645.65 | $2,290.87 |
- 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
- $302.00 / $645.65 / $1,230.27
| Professional | | $302.00 | $645.65 | $1,230.27 |