- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.63 / $317.62 / $2,000.00
| Facility | | $304.63 | $317.62 | $2,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $228.47 / $228.47 / $238.22
| Facility | 54 | $228.47 | $228.47 | $238.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.35 / $304.63 / $387.87
| Professional | | $266.35 | $304.63 | $387.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.85 / $717.30 / $820.32
| Professional | | $633.85 | $717.30 | $820.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.04 / $788.20 / $1,049.89
| Professional | | $408.04 | $788.20 | $1,049.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.63 / $402.31 / $562.39
| Facility | | $304.63 | $402.31 | $562.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.78 / $606.58 / $2,332.71
| Professional | | $328.78 | $606.58 | $2,332.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.78 / $582.66 / $826.58
| Professional | | $328.78 | $582.66 | $826.58 |