- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.14 / $2,233.46 / $4,938.67
| Facility | | $359.14 | $2,233.46 | $4,938.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.01 / $1,128.96 / $2,096.73
| Professional | | $207.01 | $1,128.96 | $2,096.73 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $134.71 / $624.12 / $815.14
| Professional | 52 | $134.71 | $624.12 | $815.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.46 / $248.30 / $290.95
| Professional | | $240.46 | $248.30 | $290.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,772.93 / $2,772.93 / $2,772.93
| Facility | | $2,772.93 | $2,772.93 | $2,772.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.52 / $599.67 / $2,433.65
| Professional | | $229.52 | $599.67 | $2,433.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.08 / $1,542.97 / $2,820.37
| Professional | | $897.08 | $1,542.97 | $2,820.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.57 / $1,486.86 / $2,462.21
| Professional | | $1,110.57 | $1,486.86 | $2,462.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.02 / $1,070.02 / $1,693.86
| Professional | | $1,070.02 | $1,070.02 | $1,693.86 |