- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $794.33 / $2,238.72
| Facility | | $107.15 | $794.33 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $112.20 / $199.53
| Professional | | $69.18 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $117.49
| Professional | 52 | $109.65 | $109.65 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $29.51 / $34.67 / $72.44
| Professional | 53 | $29.51 | $34.67 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $245.47
| Facility | | $181.97 | $181.97 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $83.18 / $134.90
| Professional | | $63.10 | $83.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $218.78
| Professional | | $117.49 | $117.49 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $123.03 / $181.97
| Professional | | $87.10 | $123.03 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $194.98
| Professional | | $128.82 | $165.96 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $354.81 / $707.95
| Facility | | $128.82 | $354.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $100.00 / $173.78
| Professional | | $61.66 | $100.00 | $173.78 |