- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $4,047.00 / $4,601.00
| Facility | | $1,017.00 | $4,047.00 | $4,601.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $22.79 / $22.79 / $22.79
| Facility | 52 | $22.79 | $22.79 | $22.79 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $9.11 / $9.11 / $9.11
| Facility | 53 | $9.11 | $9.11 | $9.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.15 / $80.84 / $87.61
| Professional | | $40.15 | $80.84 | $87.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.72 / $442.00 / $5,940.00
| Facility | | $37.72 | $442.00 | $5,940.00 |