- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.96 / $2,355.23 / $4,913.68
| Facility | | $254.96 | $2,355.23 | $4,913.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.00 / $909.33 / $1,530.89
| Facility | | $508.00 | $909.33 | $1,530.89 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $204.01 / $204.01 / $204.01
| Facility | 52 | $204.01 | $204.01 | $204.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.04 / $283.00 / $476.34
| Professional | | $224.04 | $283.00 | $476.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $453.00 / $1,330.00
| Facility | | $418.00 | $453.00 | $1,330.00 |