- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $1,230.27 / $9,120.11
| Facility | | $302.00 | $1,230.27 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $223.87 / $501.19 / $1,819.70
| Facility | 54 | $223.87 | $501.19 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $389.05 / $758.58
| Professional | | $263.03 | $389.05 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $309.03 / $446.68 / $758.58
| Professional | 54 | $309.03 | $446.68 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $3,715.35 / $9,549.93
| Facility | | $1,513.56 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $331.13 / $676.08
| Professional | | $213.80 | $331.13 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $588.84 / $2,344.23
| Facility | | $131.83 | $588.84 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Facility | 54 | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $398.11 / $891.25
| Professional | | $257.04 | $398.11 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $1,000.00 / $3,311.31
| Facility | | $208.93 | $1,000.00 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $331.13 / $707.95
| Professional | | $223.87 | $331.13 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | 54 | $87.10 | $87.10 | $87.10 |