- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,288.25 / $3,715.35
| Facility | | $275.42 | $1,288.25 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $436.52
| Professional | | $177.83 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $213.80 / $223.87 / $407.38
| Professional | 54 | $213.80 | $223.87 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $389.05 / $575.44
| Facility | | $218.78 | $389.05 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $263.03 / $331.13
| Professional | | $199.53 | $263.03 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $218.78 / $218.78
| Facility | | $39.81 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $269.15 / $363.08
| Professional | | $190.55 | $269.15 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $501.19 / $1,258.93
| Facility | | $213.80 | $501.19 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $204.17 / $338.84
| Professional | | $158.49 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Professional | 54 | $89.13 | $89.13 | $89.13 |