- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.50 / $220.50 / $618.36
| Professional | | $171.50 | $220.50 | $618.36 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $98.48 / $110.25 / $378.28
| Professional | 52 | $98.48 | $110.25 | $378.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.04 / $271.38 / $839.32
| Professional | | $187.04 | $271.38 | $839.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.44 / $921.02 / $1,599.82
| Professional | | $613.44 | $921.02 | $1,599.82 |