- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $1,445.44 / $2,398.83
| Facility | | $112.20 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | 52 | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $194.98 / $1,071.52
| Professional | | $87.10 | $194.98 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $275.42 / $707.95
| Professional | | $204.17 | $275.42 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $354.81 / $977.24
| Professional | | $154.88 | $354.81 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $436.52 / $1,122.02
| Facility | | $112.20 | $436.52 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $549.54 / $724.44
| Professional | | $316.23 | $549.54 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $302.00 / $741.31
| Professional | | $131.83 | $302.00 | $741.31 |