- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $288.40
| Professional | | $109.65 | $162.18 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $218.78
| Professional | 54 | $147.91 | $147.91 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46,773.51 / $75,857.76 / $95,499.26
| Facility | | $46,773.51 | $75,857.76 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $199.53
| Professional | | $194.98 | $194.98 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $162.18 / $204.17
| Professional | | $120.23 | $162.18 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $213.80 / $239.88
| Facility | | $199.53 | $213.80 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $213.80 / $239.88
| Professional | | $199.53 | $213.80 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $165.96 / $245.47
| Facility | | $125.89 | $165.96 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $165.96 / $263.03
| Professional | | $79.43 | $165.96 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $194.98 / $239.88
| Professional | | $125.89 | $194.98 | $239.88 |