- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.54 / $334.61 / $2,000.00
| Facility | | $307.54 | $334.61 | $2,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $230.66 / $230.66 / $250.96
| Facility | 54 | $230.66 | $230.66 | $250.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.32 / $305.93 / $352.72
| Professional | | $264.32 | $305.93 | $352.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.42 / $737.22 / $865.48
| Professional | | $640.42 | $737.22 | $865.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.58 / $800.02 / $1,106.05
| Professional | | $386.58 | $800.02 | $1,106.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.54 / $394.61 / $601.05
| Facility | | $307.54 | $394.61 | $601.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.02 / $622.00 / $2,362.32
| Professional | | $345.02 | $622.00 | $2,362.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.02 / $610.69 / $759.04
| Professional | | $345.02 | $610.69 | $759.04 |