- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.41 / $1,285.41 / $8,500.00
| Facility | | $1,285.41 | $1,285.41 | $8,500.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $642.71 / $642.71 / $642.71
| Facility | 52 | $642.71 | $642.71 | $642.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.67 / $1,199.25 / $1,702.98
| Professional | | $1,088.67 | $1,199.25 | $1,702.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,452.51 / $2,665.34 / $3,173.83
| Professional | | $2,452.51 | $2,665.34 | $3,173.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.82 / $2,937.48 / $3,793.33
| Professional | | $1,813.82 | $2,937.48 | $3,793.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.41 / $1,671.03 / $2,317.42
| Facility | | $1,285.41 | $1,671.03 | $2,317.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.83 / $2,482.42 / $9,294.87
| Professional | | $1,350.83 | $2,482.42 | $9,294.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.83 / $1,985.41 / $3,087.45
| Professional | | $1,350.83 | $1,985.41 | $3,087.45 |