- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $1,819.70
| Facility | | $588.84 | $588.84 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $158.49 / $602.56
| Facility | | $131.83 | $158.49 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $24.55 / $24.55 / $24.55
| Facility | 53 | $24.55 | $24.55 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $251.19 / $331.13
| Professional | | $147.91 | $251.19 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $331.13 / $1,000.00
| Facility | | $213.80 | $331.13 | $1,000.00 |