- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.54 / $141.38 / $469.00
| Professional | | $96.54 | $141.38 | $469.00 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $56.21 / $70.70 / $257.83
| Professional | 52 | $56.21 | $70.70 | $257.83 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $22.48 / $28.28 / $103.14
| Professional | 53 | $22.48 | $28.28 | $103.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.65 / $195.27 / $368.76
| Professional | | $165.65 | $195.27 | $368.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.36 / $148.88 / $368.76
| Professional | | $99.36 | $148.88 | $368.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.31 / $159.19 / $368.76
| Professional | | $103.31 | $159.19 | $368.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $146.31 / $452.61
| Professional | | $130.72 | $146.31 | $452.61 |