- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $678.71 / $3,089.00 / $8,049.23
| Facility | | $678.71 | $3,089.00 | $8,049.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.37 / $1,609.67 / $2,209.89
| Professional | | $303.37 | $1,609.67 | $2,209.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.81 / $2,415.46 / $8,342.00
| Facility | | $477.81 | $2,415.46 | $8,342.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $869.54 / $869.54 / $869.54
| Facility | 52 | $869.54 | $869.54 | $869.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $580.14 / $2,584.92 / $3,220.62
| Facility | | $580.14 | $2,584.92 | $3,220.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |