- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.78 / $573.78 / $10,500.00
| Facility | | $573.78 | $573.78 | $10,500.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $286.89 / $286.89 / $286.89
| Facility | 52 | $286.89 | $286.89 | $286.89 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $114.76 / $114.76 / $114.76
| Facility | 53 | $114.76 | $114.76 | $114.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.37 / $581.02 / $1,328.30
| Professional | | $530.37 | $581.02 | $1,328.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.23 / $1,206.03 / $1,424.94
| Professional | | $1,107.23 | $1,206.03 | $1,424.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.86 / $1,019.46 / $1,645.61
| Professional | | $786.86 | $1,019.46 | $1,645.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.78 / $706.08 / $1,721.34
| Facility | | $573.78 | $706.08 | $1,721.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.70 / $1,085.17 / $1,351.39
| Professional | | $635.70 | $1,085.17 | $1,351.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.49 / $1,155.82 / $1,351.39
| Professional | | $693.49 | $1,155.82 | $1,351.39 |