- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,570.40 / $6,760.83
| Facility | | $1,071.52 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $954.99 / $2,511.89
| Professional | | $645.65 | $954.99 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,584.89 / $3,981.07
| Facility | | $977.24 | $1,584.89 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | 54 | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,862.09
| Professional | | $1,412.54 | $1,548.82 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $4,365.16
| Facility | | $1,202.26 | $2,137.96 | $4,365.16 |