- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.87 / $180.87 / $633.86
| Professional | | $180.87 | $180.87 | $633.86 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $90.44 / $90.44 / $316.93
| Professional | 52 | $90.44 | $90.44 | $316.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.00 / $488.00 / $1,517.00
| Professional | | $407.00 | $488.00 | $1,517.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.98 / $431.12 / $1,343.59
| Professional | | $253.98 | $431.12 | $1,343.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.40 / $2,001.48 / $2,249.28
| Professional | | $873.40 | $2,001.48 | $2,249.28 |