- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $2,818.38 / $6,456.54
| Facility | | $338.84 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $724.44 / $1,819.70
| Professional | | $194.98 | $724.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $630.96 / $2,398.83
| Professional | | $251.19 | $630.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $1,000.00 / $1,862.09
| Professional | | $190.55 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,380.38 / $4,570.88
| Facility | | $275.42 | $1,380.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- 52
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | 52 | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- 53
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | 53 | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,819.70 / $6,025.60
| Professional | | $870.96 | $1,819.70 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $1,995.26 / $2,290.87
| Professional | | $489.78 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $1,905.46 / $2,454.71
| Professional | | $436.52 | $1,905.46 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $758.58 / $1,819.70
| Professional | | $190.55 | $758.58 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $4,466.84 / $6,165.95
| Facility | | $2,454.71 | $4,466.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $812.83 / $2,187.76
| Professional | | $229.09 | $812.83 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $467.74 / $1,819.70
| Professional | | $389.05 | $467.74 | $1,819.70 |