- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $1,614.00 / $7,727.00
| Facility | | $1,017.00 | $1,614.00 | $7,727.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $708.09 / $708.09 / $708.09
| Facility | 52 | $708.09 | $708.09 | $708.09 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $283.23 / $283.23 / $283.23
| Facility | 53 | $283.23 | $283.23 | $283.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.89 / $2,497.42 / $2,752.76
| Professional | | $1,257.89 | $2,497.42 | $2,752.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.00 / $1,319.00 / $16,382.00
| Facility | | $645.00 | $1,319.00 | $16,382.00 |