- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,000.00 / $5,623.41
| Facility | | $213.80 | $1,000.00 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $213.80 / $436.52
| Professional | | $74.13 | $213.80 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $38.90
| Professional | 52 | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $21.38
| Professional | 53 | $21.38 | $21.38 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $162.18 / $251.19
| Professional | | $89.13 | $162.18 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $954.99
| Facility | | $323.59 | $323.59 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $190.55 / $389.05
| Professional | | $93.33 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $1,023.29 / $1,819.70
| Facility | | $489.78 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $199.53 / $389.05
| Professional | | $81.28 | $199.53 | $389.05 |