- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.29 / $3,854.00 / $4,337.00
| Facility | | $531.29 | $3,854.00 | $4,337.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $114.02 / $114.02 / $114.02
| Facility | 52 | $114.02 | $114.02 | $114.02 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $45.61 / $45.61 / $45.61
| Facility | 53 | $45.61 | $45.61 | $45.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.41 / $410.43 / $444.06
| Professional | | $202.41 | $410.43 | $444.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.00 / $1,171.00 / $26,408.00
| Facility | | $808.00 | $1,171.00 | $26,408.00 |