- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.70 / $315.13 / $2,000.00
| Facility | | $287.70 | $315.13 | $2,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $215.78 / $215.78 / $236.35
| Facility | 54 | $215.78 | $215.78 | $236.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.36 / $289.67 / $487.90
| Professional | | $248.36 | $289.67 | $487.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.74 / $690.51 / $812.36
| Professional | | $593.74 | $690.51 | $812.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.71 / $742.63 / $1,035.31
| Professional | | $371.71 | $742.63 | $1,035.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.70 / $378.87 / $562.27
| Facility | | $287.70 | $378.87 | $562.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.17 / $603.51 / $2,202.23
| Professional | | $325.17 | $603.51 | $2,202.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.17 / $575.54 / $715.37
| Professional | | $325.17 | $575.54 | $715.37 |