- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.77 / $256.51 / $991.00
| Professional | | $220.77 | $256.51 | $991.00 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $113.45 / $128.26 / $626.96
| Professional | 52 | $113.45 | $128.26 | $626.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.86 / $354.16 / $1,054.35
| Professional | | $294.86 | $354.16 | $1,054.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.80 / $361.24 / $1,235.53
| Professional | | $249.80 | $361.24 | $1,235.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $333.49 / $1,054.35
| Professional | | $252.00 | $333.49 | $1,054.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.95 / $337.47 / $981.05
| Professional | | $216.95 | $337.47 | $981.05 |