- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $696.22 / $696.22 / $696.22
| Facility | | $696.22 | $696.22 | $696.22 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $348.11 / $348.11 / $348.11
| Facility | 52 | $348.11 | $348.11 | $348.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.35 / $1,176.60 / $1,963.69
| Facility | | $895.35 | $1,176.60 | $1,963.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.81 / $1,820.40 / $2,339.09
| Facility | | $1,127.81 | $1,820.40 | $2,339.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.84 / $1,259.60 / $1,478.17
| Professional | | $938.84 | $1,259.60 | $1,478.17 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $281.31 / $281.31 / $281.31
| Professional | 80 | $281.31 | $281.31 | $281.31 |
- 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 |