- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $2,290.87 / $8,128.31
| Facility | | $169.82 | $2,290.87 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $154.88 / $346.74 / $1,621.81
| Facility | 54 | $154.88 | $346.74 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $309.03
| Professional | | $107.15 | $151.36 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $331.13
| Professional | 54 | $114.82 | $194.98 | $331.13 |
- 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
- $83.18 / $144.54 / $288.40
| Professional | | $83.18 | $144.54 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $371.54 / $1,122.02
| Facility | | $79.43 | $371.54 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- 54
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | 54 | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $354.81
| Professional | | $114.82 | $169.82 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $1,000.00 / $3,311.31
| Facility | | $204.17 | $1,000.00 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $281.84
| Professional | | $97.72 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 54
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | 54 | $87.10 | $87.10 | $87.10 |