- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $2,630.27 / $5,623.41
| Facility | | $616.60 | $2,630.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $446.68 / $1,174.90
| Professional | | $169.82 | $446.68 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $177.83 / $295.12
| Professional | | $165.96 | $177.83 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $2,290.87 / $4,265.80
| Facility | | $588.84 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $549.54 / $1,071.52
| Professional | | $204.17 | $549.54 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $977.24 / $1,584.89
| Facility | | $446.68 | $977.24 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $331.13 / $1,000.00
| Professional | | $177.83 | $331.13 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $446.68 / $1,258.93
| Facility | | $173.78 | $446.68 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- 52
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $3,715.35
| Facility | 52 | $630.96 | $630.96 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $691.83 / $4,365.16
| Professional | | $186.21 | $691.83 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,621.81 / $4,466.84
| Facility | | $1,122.02 | $1,621.81 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $281.84 / $870.96
| Professional | | $162.18 | $281.84 | $870.96 |