- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,436.54 / $7,436.54 / $7,436.54
| Facility | | $7,436.54 | $7,436.54 | $7,436.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $629.00 / $2,530.00
| Facility | | $582.00 | $629.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $761.45 / $761.45 / $761.45
| Facility | 52 | $761.45 | $761.45 | $761.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.92 / $1,023.28 / $1,423.89
| Professional | | $835.92 | $1,023.28 | $1,423.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $413.00 / $1,109.00
| Facility | | $303.00 | $413.00 | $1,109.00 |