- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $3,548.13 / $7,413.10
| Facility | | $234.42 | $3,548.13 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $489.78
| Professional | | $177.83 | $251.19 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $575.44
| Professional | 54 | $213.80 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $331.13
| Professional | | $104.71 | $104.71 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $295.12
| Professional | 54 | $109.65 | $109.65 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $2,344.23 / $4,168.69
| Facility | | $758.58 | $2,344.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $275.42 / $389.05
| Professional | | $173.78 | $275.42 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $2,511.89
| Facility | | $177.83 | $177.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $281.84 / $489.78
| Professional | | $190.55 | $281.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $281.84 / $489.78
| Professional | | $229.09 | $281.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $288.40
| Professional | 54 | $275.42 | $275.42 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $380.19 / $446.68
| Professional | | $309.03 | $380.19 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,318.26 / $2,344.23
| Facility | | $213.80 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $239.88 / $446.68
| Professional | | $158.49 | $239.88 | $446.68 |