- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,344.23 / $7,943.28
| Facility | | $575.44 | $2,344.23 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $831.76 / $1,202.26 / $2,344.23
| Facility | 54 | $831.76 | $1,202.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $562.34 / $1,202.26
| Professional | | $457.09 | $562.34 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,168.69 / $10,000.00
| Facility | | $1,584.89 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $645.65 / $1,202.26
| Professional | | $457.09 | $645.65 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,148.15 / $3,981.07
| Facility | | $562.34 | $1,148.15 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Facility | 54 | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $741.31 / $1,548.82
| Professional | | $501.19 | $741.31 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $6,309.57
| Facility | | $1,000.00 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $1,122.02
| Professional | | $426.58 | $602.56 | $1,122.02 |