- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $354.81 / $870.96
| Professional | | $275.42 | $354.81 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | 54 | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $457.09 / $1,174.90
| Professional | | $269.15 | $457.09 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $645.65 / $977.24
| Professional | | $398.11 | $645.65 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $512.86 / $933.25
| Professional | | $309.03 | $512.86 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $562.34 / $691.83
| Professional | | $457.09 | $562.34 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $616.60 / $1,000.00
| Professional | | $389.05 | $616.60 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | 54 | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $457.09 / $1,174.90
| Professional | | $269.15 | $457.09 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $478.63 / $1,000.00
| Professional | | $302.00 | $478.63 | $1,000.00 |