- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $3,981.07
| Facility | | $416.87 | $416.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $141.25 / $371.54
| Professional | | $93.33 | $141.25 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | 52 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $141.25 / $218.78
| Professional | | $104.71 | $141.25 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $177.83 / $239.88
| Professional | | $125.89 | $177.83 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $144.54 / $251.19
| Professional | | $95.50 | $144.54 | $251.19 |