- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $566.13 / $667.46 / $1,121.33
| Facility | | $566.13 | $667.46 | $1,121.33 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $221.01 / $221.01 / $221.01
| Facility | 52 | $221.01 | $221.01 | $221.01 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $55.25 / $55.25 / $55.25
| Facility | 53 | $55.25 | $55.25 | $55.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.67 / $305.32 / $517.10
| Professional | | $238.67 | $305.32 | $517.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $453.00 / $1,330.00
| Facility | | $418.00 | $453.00 | $1,330.00 |