- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $169.82 / $3,715.35
| Facility | | $123.03 | $169.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $22.91 / $50.12
| Professional | | $11.75 | $22.91 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $19.95 / $39.81 / $100.00
| Professional | 50 | $19.95 | $39.81 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $12.02 / $12.02 / $12.02
| Professional | 52 | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $14.13 / $26.30
| Professional | | $12.02 | $14.13 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $21.88 / $30.20
| Professional | | $12.02 | $21.88 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,412.54 / $6,456.54
| Facility | | $316.23 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $18.20 / $31.62
| Professional | | $12.88 | $18.20 | $31.62 |