- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.68 / $977.57 / $4,803.39
| Facility | | $209.68 | $977.57 | $4,803.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.37 / $217.09 / $257.01
| Professional | | $80.37 | $217.09 | $257.01 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $39.90 / $42.28 / $128.51
| Professional | 52 | $39.90 | $42.28 | $128.51 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $15.96 / $16.91 / $51.40
| Professional | 53 | $15.96 | $16.91 | $51.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.62 / $202.01 / $292.06
| Professional | | $101.62 | $202.01 | $292.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.58 / $2,565.42 / $3,350.73
| Facility | | $1,228.58 | $2,565.42 | $3,350.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $5,000.00 / $5,000.00
| Facility | | $5,000.00 | $5,000.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.31 / $264.33 / $475.64
| Professional | | $205.31 | $264.33 | $475.64 |