- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.10 / $2,521.67 / $5,043.08
| Facility | | $157.10 | $2,521.67 | $5,043.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.13 / $178.13 / $190.24
| Professional | | $61.13 | $178.13 | $190.24 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $30.57 / $38.28 / $93.57
| Professional | 52 | $30.57 | $38.28 | $93.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.72 / $118.88 / $306.88
| Professional | | $73.72 | $118.88 | $306.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,842.41 / $2,842.41 / $2,842.41
| Facility | | $2,842.41 | $2,842.41 | $2,842.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.84 / $228.18 / $435.50
| Professional | | $168.84 | $228.18 | $435.50 |