- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,587.04 / $3,666.78 / $7,119.04
| Facility | | $1,587.04 | $3,666.78 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.51 / $771.11 / $1,462.18
| Professional | | $455.51 | $771.11 | $1,462.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.53 / $1,167.65 / $1,966.00
| Facility | | $746.53 | $1,167.65 | $1,966.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $1,534.41 / $1,534.41 / $1,534.41
| Facility | 54 | $1,534.41 | $1,534.41 | $1,534.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.05 / $1,183.39 / $1,597.29
| Facility | | $981.05 | $1,183.39 | $1,597.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,640.00 / $2,126.00
| Facility | | $1,204.00 | $1,640.00 | $2,126.00 |