- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $3,715.35 / $4,265.80
| Facility | | $363.08 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,318.26 / $1,513.56
| Facility | | $630.96 | $1,318.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | 52 | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $269.15 / $398.11
| Professional | | $204.17 | $269.15 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $2,511.89
| Facility | | $724.44 | $1,071.52 | $2,511.89 |