- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $331.13 / $794.33
| Facility | | $257.04 | $331.13 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $398.11 / $724.44
| Professional | | $302.00 | $398.11 | $724.44 |
- 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
- $575.44 / $870.96 / $1,318.26
| Professional | | $575.44 | $870.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,318.26 / $3,162.28
| Facility | | $933.25 | $1,318.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,047.13 / $1,584.89
| Professional | | $630.96 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,288.25 / $2,511.89
| Facility | | $1,047.13 | $1,288.25 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $912.01 / $1,445.44
| Professional | | $630.96 | $912.01 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $575.44 / $1,000.00
| Facility | | $331.13 | $575.44 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | 54 | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $691.83 / $2,454.71
| Professional | | $354.81 | $691.83 | $2,454.71 |
- 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
- $323.59 / $676.08 / $1,288.25
| Professional | | $323.59 | $676.08 | $1,288.25 |