- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $338.84 / $338.84
| Facility | | $316.23 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $338.84 / $660.69
| Professional | | $275.42 | $338.84 | $660.69 |
- 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
- $537.03 / $812.83 / $1,230.27
| Professional | | $537.03 | $812.83 | $1,230.27 |
- 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
- $588.84 / $977.24 / $1,479.11
| Professional | | $588.84 | $977.24 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,202.26 / $2,398.83
| Facility | | $977.24 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $851.14 / $1,380.38
| Professional | | $575.44 | $851.14 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $537.03 / $954.99
| Facility | | $309.03 | $537.03 | $954.99 |
- 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
- $331.13 / $645.65 / $2,290.87
| Professional | | $331.13 | $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 |