- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $2,089.30 / $5,623.41
| Facility | | $707.95 | $2,089.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | 54 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $660.69 / $1,258.93
| Professional | | $478.63 | $660.69 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,122.02
| Professional | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,290.87 / $3,019.95
| Facility | | $1,348.96 | $2,290.87 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $794.33 / $1,202.26
| Professional | | $562.34 | $794.33 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $724.44 / $1,122.02
| Professional | | $512.86 | $724.44 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $4,897.79 / $45,708.82
| Facility | | $4,897.79 | $4,897.79 | $45,708.82 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | 54 | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,981.07 / $4,786.30 / $4,786.30
| Professional | | $3,981.07 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,412.54 / $2,884.03
| Facility | | $741.31 | $1,412.54 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $630.96 / $1,071.52
| Professional | | $457.09 | $630.96 | $1,071.52 |