- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.04 / $2,613.30 / $6,263.60
| Facility | | $975.04 | $2,613.30 | $6,263.60 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $66.84 / $66.84 / $217.48
| Facility | 53 | $66.84 | $66.84 | $217.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.23 / $1,077.25 / $1,629.69
| Professional | | $334.23 | $1,077.25 | $1,629.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.01 / $837.34 / $2,152.04
| Professional | | $647.01 | $837.34 | $2,152.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.88 / $978.92 / $2,338.44
| Professional | | $418.88 | $978.92 | $2,338.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.88 / $2,847.54 / $4,040.48
| Facility | | $455.88 | $2,847.54 | $4,040.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.90 / $2,054.15 / $2,850.35
| Professional | | $1,184.90 | $2,054.15 | $2,850.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,753.00 / $5,753.00 / $5,753.00
| Facility | | $5,753.00 | $5,753.00 | $5,753.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.33 / $2,187.88 / $2,850.35
| Professional | | $1,265.33 | $2,187.88 | $2,850.35 |