- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.62 / $1,120.60 / $2,662.80
| Professional | | $711.62 | $1,120.60 | $2,662.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.15 / $1,832.08 / $4,645.00
| Facility | | $1,158.15 | $1,832.08 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $3,154.80 / $3,154.80 / $3,154.80
| Facility | 54 | $3,154.80 | $3,154.80 | $3,154.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.44 / $1,676.12 / $2,020.28
| Facility | | $1,257.44 | $1,676.12 | $2,020.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,101.36 / $3,894.74 / $6,267.00
| Facility | | $2,101.36 | $3,894.74 | $6,267.00 |