- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $2,089.30 / $7,943.28
| Facility | | $363.08 | $2,089.30 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $239.88 / $645.65 / $1,819.70
| Facility | 54 | $239.88 | $645.65 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $398.11 / $977.24
| Professional | | $281.84 | $398.11 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,630.78 / $8,709.64
| Facility | | $1,479.11 | $3,630.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $380.19 / $741.31
| Professional | | $263.03 | $380.19 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $524.81 / $2,630.27
| Facility | | $120.23 | $524.81 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | 54 | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $457.09 / $1,000.00
| Professional | | $309.03 | $457.09 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $1,071.52 / $3,467.37
| Facility | | $204.17 | $1,071.52 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $371.54 / $707.95
| Professional | | $263.03 | $371.54 | $707.95 |