- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.59 / $2,354.48 / $5,549.60
| Facility | | $164.59 | $2,354.48 | $5,549.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $697.26 / $1,987.71 / $4,602.53
| Facility | | $697.26 | $1,987.71 | $4,602.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.00 / $875.00 / $2,720.17
| Facility | | $120.00 | $875.00 | $2,720.17 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $94.25 / $94.25 / $94.25
| Facility | 52 | $94.25 | $94.25 | $94.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.11 / $182.93 / $487.68
| Professional | | $123.11 | $182.93 | $487.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $815.00 / $2,588.00 / $4,780.00
| Facility | | $815.00 | $2,588.00 | $4,780.00 |