- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,865.51 / $17,356.75 / $17,356.75
| Facility | | $6,865.51 | $17,356.75 | $17,356.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.15 / $444.32 / $1,993.56
| Professional | | $198.15 | $444.32 | $1,993.56 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $123.47 / $182.06 / $996.78
| Professional | 52 | $123.47 | $182.06 | $996.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.86 / $507.69 / $1,916.98
| Professional | | $289.86 | $507.69 | $1,916.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.72 / $507.18 / $2,233.81
| Professional | | $298.72 | $507.18 | $2,233.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.58 / $512.86 / $1,872.26
| Professional | | $259.58 | $512.86 | $1,872.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,865.51 / $6,865.51 / $17,356.75
| Facility | | $6,865.51 | $6,865.51 | $17,356.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.00 / $427.86 / $2,068.05
| Professional | | $207.00 | $427.86 | $2,068.05 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $123.47 / $182.06 / $996.78
| Professional | 52 | $123.47 | $182.06 | $996.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.44 / $1,665.21 / $2,420.34
| Professional | | $1,230.44 | $1,665.21 | $2,420.34 |