- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $295.12 / $630.96
| Professional | | $181.97 | $295.12 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $302.00 / $467.74 / $575.44
| Professional | 54 | $302.00 | $467.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $218.78 / $354.81
| Professional | | $177.83 | $218.78 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $104.71 / $131.83 / $234.42
| Professional | 54 | $104.71 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $309.03 / $416.87
| Professional | | $194.98 | $309.03 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $234.42 / $426.58
| Professional | | $158.49 | $234.42 | $426.58 |