- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.71 / $293.77 / $1,731.63
| Professional | | $227.71 | $293.77 | $1,731.63 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $135.27 / $135.27 / $772.78
| Professional | 52 | $135.27 | $135.27 | $772.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.40 / $1,513.40 / $4,461.80
| Professional | | $1,513.40 | $1,513.40 | $4,461.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.89 / $1,682.74 / $4,461.80
| Professional | | $296.89 | $1,682.74 | $4,461.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.89 / $1,682.74 / $4,461.80
| Professional | | $296.89 | $1,682.74 | $4,461.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.62 / $1,867.66 / $5,476.37
| Professional | | $1,754.62 | $1,867.66 | $5,476.37 |