- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $794.33 / $2,041.74
| Facility | | $112.20 | $794.33 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $213.80 / $436.52
| Professional | | $75.86 | $213.80 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $218.78
| Professional | 52 | $158.49 | $158.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $19.50 / $38.90 / $104.71
| Professional | 53 | $19.50 | $38.90 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $870.96
| Facility | | $630.96 | $630.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $107.15 / $316.23
| Professional | | $81.28 | $107.15 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $467.74
| Professional | | $251.19 | $251.19 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $363.08
| Professional | | $120.23 | $213.80 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $245.47 / $407.38
| Professional | | $104.71 | $245.47 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $954.99 / $1,995.26
| Facility | | $346.74 | $954.99 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $186.21 / $323.59
| Professional | | $79.43 | $186.21 | $323.59 |