- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $3,630.78 / $7,943.28
| Facility | | $407.38 | $3,630.78 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $208.93 / $416.87
| Professional | | $162.18 | $208.93 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | 54 | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $223.87
| Professional | | $213.80 | $213.80 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $123.03
| Professional | 54 | $117.49 | $117.49 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $776.25 / $1,174.90
| Facility | | $575.44 | $776.25 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $269.15
| Professional | | $251.19 | $251.19 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $251.19 / $389.05
| Professional | | $186.21 | $251.19 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $269.15 / $549.54
| Facility | | $177.83 | $269.15 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $288.40 / $1,548.82
| Professional | | $194.98 | $288.40 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $407.38 / $1,905.46
| Facility | | $181.97 | $407.38 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $218.78 / $309.03
| Professional | | $173.78 | $218.78 | $309.03 |