- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.12 / $1,594.12 / $1,955.70
| Facility | | $475.12 | $1,594.12 | $1,955.70 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $356.34 / $356.34 / $401.69
| Facility | 54 | $356.34 | $356.34 | $401.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $647.69 / $812.70 / $1,235.41
| Facility | | $647.69 | $812.70 | $1,235.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.00 / $1,183.39 / $1,969.98
| Facility | | $953.00 | $1,183.39 | $1,969.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.25 / $860.44 / $1,051.85
| Professional | | $592.25 | $860.44 | $1,051.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Facility | | $821.00 | $821.00 | $821.00 |