- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,137.96 / $4,073.80
| Facility | | $575.44 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $537.03 / $1,000.00
| Professional | | $426.58 | $537.03 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,513.56 / $2,137.96
| Facility | | $724.44 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $1,148.15
| Professional | | $524.81 | $741.31 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $1,071.52
| Professional | | $489.78 | $676.08 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $19,498.45
| Facility | | $3,019.95 | $3,019.95 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | 54 | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,570.88 / $4,570.88
| Professional | | $3,801.89 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $977.24
| Professional | | $426.58 | $575.44 | $977.24 |