- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $629.00 / $2,530.00
| Facility | | $582.00 | $629.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $1,471.60 / $1,471.60 / $1,471.60
| Facility | 52 | $1,471.60 | $1,471.60 | $1,471.60 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $183.95 / $183.95 / $183.95
| Facility | AS | $183.95 | $183.95 | $183.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.16 / $2,033.64 / $2,788.39
| Professional | | $1,614.16 | $2,033.64 | $2,788.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $362.00 / $1,109.00
| Facility | | $303.00 | $362.00 | $1,109.00 |