- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.25 / $235.35 / $1,004.00
| Professional | | $78.25 | $235.35 | $1,004.00 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $47.25 / $117.68 / $520.59
| Professional | 52 | $47.25 | $117.68 | $520.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.84 / $798.84 / $971.68
| Facility | | $798.84 | $798.84 | $971.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.04 / $259.38 / $696.86
| Professional | | $220.04 | $259.38 | $696.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.51 / $220.95 / $696.86
| Professional | | $89.51 | $220.95 | $696.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.63 / $288.89 / $696.86
| Professional | | $95.63 | $288.89 | $696.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.37 / $275.86 / $855.32
| Professional | | $228.37 | $275.86 | $855.32 |