- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.85 / $355.80 / $3,706.14
| Facility | | $241.85 | $355.80 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.48 / $41.21 / $104.55
| Professional | | $29.48 | $41.21 | $104.55 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $12.72 / $20.61 / $52.28
| Professional | 52 | $12.72 | $20.61 | $52.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.43 / $59.40 / $117.17
| Professional | | $30.43 | $59.40 | $117.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.84 / $55.17 / $146.43
| Professional | | $32.84 | $55.17 | $146.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.29 / $98.76 / $134.52
| Professional | | $65.29 | $98.76 | $134.52 |