- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.00 / $4,784.00 / $6,150.00
| Facility | | $1,614.00 | $4,784.00 | $6,150.00 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $3,807.00 / $3,807.00 / $3,807.00
| Facility | 50 | $3,807.00 | $3,807.00 | $3,807.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $747.24 / $747.24 / $747.24
| Facility | 52 | $747.24 | $747.24 | $747.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.42 / $3,291.71 / $3,291.71
| Professional | | $1,579.42 | $3,291.71 | $3,291.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $2,343.00 / $26,408.00
| Facility | | $1,832.00 | $2,343.00 | $26,408.00 |