- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.65 / $2,181.87 / $5,549.00
| Facility | | $182.65 | $2,181.87 | $5,549.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.87 / $158.07 / $394.72
| Professional | | $86.87 | $158.07 | $394.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.19 / $225.14 / $1,607.00
| Facility | | $125.19 | $225.14 | $1,607.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $237.37 / $237.37 / $237.37
| Facility | 52 | $237.37 | $237.37 | $237.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.79 / $225.14 / $361.25
| Facility | | $148.79 | $225.14 | $361.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.00 / $1,640.00 / $3,560.25
| Facility | | $1,151.00 | $1,640.00 | $3,560.25 |