- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $169.82 / $169.82
| Facility | | $147.91 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $389.05
| Professional | | $134.90 | $169.82 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $812.83 / $2,137.96
| Facility | | $323.59 | $812.83 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $389.05 / $616.60
| Professional | | $257.04 | $389.05 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $630.96 / $1,513.56
| Facility | | $446.68 | $630.96 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $478.63 / $758.58
| Professional | | $295.12 | $478.63 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $616.60 / $1,202.26
| Facility | | $489.78 | $616.60 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $436.52 / $691.83
| Professional | | $288.40 | $436.52 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $295.12 / $691.83
| Facility | | $158.49 | $295.12 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $478.63
| Facility | 54 | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $331.13 / $1,096.48
| Professional | | $165.96 | $331.13 | $1,096.48 |
- 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
- $151.36 / $309.03 / $575.44
| Professional | | $151.36 | $309.03 | $575.44 |