- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $34.67 / $57.54
| Professional | | $28.84 | $34.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $41.69 / $41.69 / $41.69
| Professional | 52 | $41.69 | $41.69 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $33.11
| Professional | | $33.11 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $630.96
| Facility | | $512.86 | $512.86 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $29.51 / $34.67
| Professional | | $22.39 | $29.51 | $34.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Facility | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $47.86 / $66.07
| Professional | | $29.51 | $47.86 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $33.11 / $79.43
| Professional | | $30.90 | $33.11 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $41.69 / $74.13
| Facility | | $29.51 | $41.69 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $47.86 / $66.07
| Professional | | $29.51 | $47.86 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $47.86 / $67.61
| Professional | | $33.11 | $47.86 | $67.61 |