- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $331.13 / $794.33
| Facility | | $316.23 | $331.13 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $331.13 / $676.08
| Professional | | $275.42 | $331.13 | $676.08 |
- 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 / $1,202.26
| Professional | | $524.81 | $812.83 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,202.26 / $2,884.03
| Facility | | $851.14 | $1,202.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $977.24 / $1,445.44
| Professional | | $575.44 | $977.24 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,174.90 / $2,290.87
| Facility | | $933.25 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $851.14 / $1,318.26
| Professional | | $562.34 | $851.14 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $562.34 / $933.25
| Facility | | $316.23 | $562.34 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | 54 | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $630.96 / $2,344.23
| Professional | | $316.23 | $630.96 | $2,344.23 |
- 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
- $309.03 / $645.65 / $1,230.27
| Professional | | $309.03 | $645.65 | $1,230.27 |