- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.69 / $334.86 / $492.27
| Professional | | $241.69 | $334.86 | $492.27 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $220.91 / $251.15 / $369.20
| Professional | 54 | $220.91 | $251.15 | $369.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.85 / $411.11 / $628.07
| Professional | | $309.85 | $411.11 | $628.07 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $198.57 / $251.52 / $295.91
| Professional | 54 | $198.57 | $251.52 | $295.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.39 / $517.97 / $685.74
| Professional | | $337.39 | $517.97 | $685.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.64 / $475.33 / $721.26
| Professional | | $272.64 | $475.33 | $721.26 |