- 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
- $142.24 / $142.24 / $142.24
| Facility | 52 | $142.24 | $142.24 | $142.24 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $56.89 / $56.89 / $56.89
| Facility | 53 | $56.89 | $56.89 | $56.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.93 / $517.10 / $553.91
| Professional | | $251.93 | $517.10 | $553.91 |
- 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 |