- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $263.03 / $831.76
| Professional | | $114.82 | $263.03 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $302.00 / $933.25
| Professional | | $131.83 | $302.00 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $457.09
| Facility | | $199.53 | $199.53 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Facility | 52 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $316.23 / $1,148.15
| Professional | | $144.54 | $316.23 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $489.78 / $1,445.44
| Professional | | $131.83 | $489.78 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $354.81 / $1,122.02
| Professional | | $134.90 | $354.81 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $309.03 / $1,047.13
| Professional | | $131.83 | $309.03 | $1,047.13 |