- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.98 / $3,719.62 / $5,536.99
| Facility | | $180.98 | $3,719.62 | $5,536.99 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $90.49 / $90.49 / $90.49
| Facility | 52 | $90.49 | $90.49 | $90.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.71 / $327.24 / $553.57
| Facility | | $223.71 | $327.24 | $553.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.69 / $510.69 / $2,030.75
| Facility | | $307.69 | $510.69 | $2,030.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.80 / $327.96 / $373.91
| Professional | | $247.80 | $327.96 | $373.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |